Gender differences in adverse drug reactions

Gender-based personalized pharmacotherapy: a systematic review

PURPOSE

In general, male and female are prescribed the same amount of dosage even if most of the cases female required less dosage than male. Physicians are often facing problem on appropriate drug dosing, efficient treatment, and drug safety for a female in general. To identify and synthesize evidence about the effectiveness of gender-based therapy; provide the information to patients, providers, and health system intervention to ensure safety treatment; and minimize adverse effects.

METHODS

We performed a systematic review to evaluate the effect of gender difference on pharmacotherapy. Published articles from January 1990 to December 2015 were identified using specific term in MEDLINE (PubMed), EMBASE, and the Cochrane library according to search strategies that strengthen the reporting of observational and clinical studies.

RESULTS

Twenty-six studies fulfilled the inclusion criteria for this systematic review, yielding a total of 6309 subjects. We observed that female generally has a lower the gastric emptying time, gastric PH, lean body mass, and higher plasma volume, BMI, body fat, as well as reduce hepatic clearance, difference in activity of Cytochrome P450 enzyme, and metabolize drugs at different rate compared with male. Other significant factors such as conjugation, protein binding, absorption, and the renal elimination could not be ignored. However, these differences can lead to adverse effects in female especially for the pregnant, post-menopausal, and elderly women.

CONCLUSION

This systematic review provides an evidence for the effectiveness of dosage difference to ensure safety and efficient treatment. Future studies on the current topic are, therefore, recommended to reduce the adverse effect of therapy.

Subjective Report of Side Effects of Prescribed and Nonprescribed Psychostimulant Use in Young Adults

BACKGROUND

Side effects of prescribed and nonprescribed psychostimulant use are understudied.

OBJECTIVES

The study examined side effects of prescribed and nonprescribed psychostimulant use in a college sample with attention to possible gender differences.

METHODS

2716 undergraduates (1448 male) between the ages of 17 and 57 years (M = 19.43 years, SD = 1.7 years) completed an online survey that included questions about the subjective side effects of prescribed and nonprescribed psychostimulant use.

RESULTS

Results suggested that prescribed users more frequently reported side effects, compared to nonprescribed users. For prescribed users, females more frequently reported appetite, somatic, and anxiety-related side effects compared to males. For nonprescribed users, while females reported more somatic and anxiety-related side effects, males more frequently reported loss of sex drive and sweating as side effects. Conclusions/Importance: These findings suggest prescribed users of psychostimulants more frequently report side effects with prominent gender differences in line with gender roles.

No substantial gender differences in suspected adverse reactions to ACE inhibitors and ARBs: results from spontaneous reporting system in Campania Region

BACKGROUND

Today, there is a poor knowledge about gender differences in adverse drug reactions (ADRs) to cardiovascular drugs such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Therefore, the aim of this study was to analyze spontaneous reports of suspected ADRs induced by ACE-inhibitors and ARBs, between January 2001 and June 2015, recorded in a Region of Southern Italy (Campania Region).

METHODS

We performed a descriptive gender-related analysis of regional safety data, obtained from the spontaneous reporting system.

RESULTS

In the considered period, 772 suspected ADRs to ACE inhibitors and ARBs (in monotherapy or in combination) were reported with a slightly higher frequency in men compared with women. In both genders, the most involved category was ARBs in combination, whereas the most prescribed active substance was ramipril. General and administration site conditions, vascular disorders and modification of laboratory parameters were more common in men, while respiratory disorders were most common in women. In 88.2% of cases, not serious ADRs were described more by men than women.

CONCLUSIONS

This analysis suggested no substantial gender differences. Further studies such as randomized population studies or meta-analysis of ACE inhibitors and ARBs randomized studies are needed to clarify whether gender differences exist in the safety profile of these drugs.

Linking the Epigenome with Exposure Effects and Susceptibility: The Epigenetic Seed and Soil Model

The epigenome is a dynamic mediator of gene expression that shapes the way that cells, tissues, and organisms respond to their environment. Initial studies in the emerging field of "toxicoepigenetics" have described either the impact of an environmental exposure on the epigenome or the association of epigenetic signatures with the onset or progression of disease; however, the majority of these pioneering studies examined the relationship between discrete epigenetic modifications and the effects of a single environmental factor. Although these data provide critical blocks with which we construct our understanding of the role of the epigenome in susceptibility and disease, they are akin to individual letters in a complex alphabet that is used to compose the language of the epigenome. Advancing the use of epigenetic data to gain a more comprehensive understanding of the mechanisms underlying exposure effects, identify susceptible populations, and inform the next generation risk assessment depends on our ability to integrate these data in a way that accounts for their cumulative impact on gene regulation. Here we will review current examples demonstrating associations between the epigenetic impacts of intrinsic factors, such as such as age, genetics, and sex, and environmental exposures shape the epigenome and susceptibility to exposure effects and disease. We will also demonstrate how the "epigenetic seed and soil" model can be used as a conceptual framework to explain how epigenetic states are shaped by the cumulative impacts of intrinsic and extrinsic factors and how these in turn determine how an individual responds to subsequent exposure to environmental stressors.

Drugs and Medical Devices: Adverse Events and the Impact on Women's Health

A large number of medications and medical devices removed from the market by the US Food and Drug Administration over the past 4 decades specifically posed greater health risks to women. This article reviews the historical background of sex and gender in clinical research policy and describes several approved drugs and devices targeted for use in women that have caused major morbidity and mortality. The intended population for the medications and devices, population affected, approval process, and the basic and legal actions taken against the medication/drug company are also discussed. It is recognized that women are still at risk for harm from unsafe medications and devices, and continued improvements in legislation that promotes inclusion of sex and gender into the design and analysis of research will improve safety for both men and women.

An assessment of reported adverse drug reactions in a Tertiary Care Hospital in South India: A retrospective cross-sectional study

Objective:

The primary objective of this study was to assess the causality of ADRs using World Health Organization-Uppsala Monitoring Centre (WHO–UMC), Naranjo and Liverpool ADR Causality Assessment Tool (LCAT). Other primary objective was to assess the agreement between the WHO-UMC criterion, Naranjo algorithm and LCAT. The secondary objective was to assess the reported adverse drug reactions in a tertiary care hospital in South India.

Materials and Methods:

This was a cross-sectional retrospective study. All the ADRs which were reported by the Pharmacovigilance Unit between July 2016 and March 2017 were assessed. Causality assessment was performed by two well-trained independent pharmacologists by applying the three methods–WHO, Naranjo and LCAT. Concurrence between the two algorithms was compared using the Cohen's weighted kappa statistic.

Results:

Causality assessment of adverse reactions according to Naranjo criteria shows that 81% cases were of probable type, 9.5% cases were possible and 9.5% cases were unlikely. Causality assessment of adverse reactions according to WHO-UMC criteria shows that 85.7% cases were of probable type, 4.8% cases were possible, 4.8% cases were unlikely and 4.8% cases were definite. Causality assessment of adverse reactions according to Liverpool criteria shows that 61.9% cases were of probable type, 4.8% cases were possible and 33.3% cases were definite. Cohen's kappa test shows that negative and poor concurrence was seen between WHO and Naranjo causality comparison (κ = −0.161). Positive but poor concurrence based on kappa values was seen between Liverpool and Naranjo's causality comparison (κ = 0.133). Negative and poor concurrence based on kappa values was seen between WHO and Liverpool causality comparison (κ = −0.161).

Conclusion:

The most frequent causality category observed by the WHO-UMC criteria, Naranjo as well as the Liverpool algorithm was “Probable.” Full concurrence was not found between any of two scales of causality assessment.

Oral Adverse Drug Reactions to Cardiovascular Drugs

A great many cardiovascular drugs (CVDs) have the potential to induce adverse reactions in the mouth. The prevalence of such reactions is not known, however, since many are asymptomatic and therefore are believed to go unreported. As more drugs are marketed and the population includes an increasing number of elderly, the number of drug prescriptions is also expected to increase. Accordingly, it can be predicted that the occurrence of adverse drug reactions (ADRs), including the oral ones (ODRs), will continue to increase. ODRs affect the oral mucous membrane, saliva production, and taste. The pathogenesis of these reactions, especially the mucosal ones, is largely unknown and appears to involve complex interactions among the drug in question, other medications, the patient’s underlying disease, genetics, and life-style factors. Along this line, there is a growing interest in the association between pharmacogenetic polymorphism and ADRs. Research focusing on polymorphism of the cytochrome P450 system (CYPs) has become increasingly important and has highlighted the intra- and inter-individual responses to drug exposure. This system has recently been suggested to be an underlying candidate regarding the pathogenesis of ADRs in the oral mucous membrane. This review focuses on those CVDs reported to induce ODRs. In addition, it will provide data on specific drugs or drug classes, and outline and discuss recent research on possible mechanisms linking ADRs to drug metabolism patterns. Abbreviations used will be as follows: ACEI, ACE inhibitor; ADR, adverse drug reaction; ANA, antinuclear antigen; ARB, angiotensin II receptor blocker; BAB, beta-adrenergic blocker; CCB, calcium-channel blocker; CDR, cutaneous drug reaction; CVD, cardiovascular drug; CYP, cytochrome P450 enzyme; EM, erythema multiforme; FDE, fixed drug eruption; I, inhibitor of CYP isoform activity; HMG-CoA, hydroxymethyl-glutaryl coenzyme A; NAT, N-acetyltransferase; ODR, oral drug reaction; RDM, reactive drug metabolite; S, substrate for CYP isoform; SJS, Stevens-Johnson syndrome; SLE, systemic lupus erythematosus; and TEN, toxic epidermal necrolysis.

Gender differences in side effects and attitudes regarding statin use in the Understanding Statin Use in America and Gaps in Patient Education (USAGE) study

BACKGROUND

Statin therapy has been shown to reduce cardiovascular morbidity and mortality, and the benefits of statin therapy are similar for men and women. Recent studies have shown that women are less likely to be treated with statin therapy, to be on higher doses of more potent statins, and to achieve their lipid goals as compared with men.

OBJECTIVES

To analyze results from the Understanding Statin Use in America and Gaps in Patient Education (USAGE) survey and to assess whether women differ from men with regard to reported side effects associated with statin use, clinician and patient interactions, as well as general attitudes and preferences regarding statin use.

METHODS

The study population was derived from participants in the USAGE survey, a self-administered, Internet-based questionnaire.

RESULTS

More women reported switching or stopping a statin because of side effects compared with men. New or worsening muscle symptoms were reported in 31% of women compared with 26% of men (P < .01). More women, including high-risk women reported that their doctor did not give them information about their risk for heart disease compared with men. Women were more likely to try 3 or more statins, but less likely to use alternative low-density lipoprotein cholesterol-lowering drugs. Women were more likely to be dissatisfied with their statin, with how their clinician explained their cholesterol treatment, and less adherent to their statin than men.

CONCLUSIONS

Women are more likely to stop or switch their statin than men, and the main reason for this was new or worsening muscle symptoms. Improved communication between the clinician and the patient about the benefits and risks of statin therapy will improve adherence, lipid goal attainment, and outcomes in women with or at risk for cardiovascular disease.

Patterns of Adverse Drug Reactions in Different Age Groups: Analysis of Spontaneous Reports by Community Pharmacists

Purpose

To evaluate the clinical manifestations and causative drugs associated with adverse drug reactions (ADRs) spontaneously reported by community pharmacists and to compare the ADRs by age.

Methods

ADRs reported to the Regional Pharmacovigilance Center of the Korean Pharmaceutical Association by community pharmacists from January 2013 to June 2014 were included. Causality was assessed using the WHO-Uppsala Monitoring Centre system. The patient population was classified into three age groups. We analyzed 31,398 (74.9%) ADRs from 9,705 patients, identified as having a causal relationship, from a total pool of 41,930 ADRs from 9,873 patients. Median patient age was 58.0 years; 66.9% were female.

Results

Gastrointestinal system (34.4%), nervous system (14.4%), and psychiatric (12.1%) disorders were the most frequent symptoms. Prevalent causative drugs were those for acid-related disorders (11.4%), anti-inflammatory products (10.5%), analgesics (7.2%), and antibacterials (7.1%). Comparisons by age revealed diarrhea and antibacterials to be most commonly associated with ADRs in children (p < 0.001), whereas dizziness was prevalent in the elderly (p < 0.001). Anaphylactic reaction was the most frequent serious event (19.7%), mainly associated with cephalosporins and non-steroidal anti-inflammatory drugs. Among 612 ADRs caused by nonprescription drugs, the leading symptoms and causative drugs were skin disorders (29.6%) and non-steroidal anti-inflammatory drugs (16.2%), respectively.

Conclusions

According to the community pharmacist reports, the leading clinical manifestations and causative drugs associated with ADRs in outpatients differed among age groups.

Number of drugs most frequently found to be independent risk factors for serious adverse reactions: a systematic literature review

In order to reduce the numbers of medication errors (MEs) that cause adverse reactions (ARs) many authors have tried to identify patient-related risk factors. However, the evidence remains controversial. The aim was to review systematically the evidence on the relationship between patient-related risk factors and the risk of serious ARs. A systematic search in Pubmed, Embase, Cochrane Systematic Reviews, Psychinfo and SweMed+ was performed. Included full text articles were hand searched for further references. Peer reviewed papers including adults from primary and secondary healthcare were included if they clearly defined seriousness of the ARs and described correlations to risk factors by statistical analysis. A total of 28 studies were identified including 85,212 patients with 3385 serious ARs, resulting in an overall frequency of serious ARs in 4% of patients. Age, gender and number of drugs were by far the most frequently investigated risk factors. The total number of drugs was the most consistent correlated risk factor found in both univariate and multivariate analyses. The number of drugs is the most frequently documented independent patient-related risk factor for serious ARs in both the general adult population as well as in the elderly. The existing evidence is however conflicting due to heterogeneity of populations and study methods. The knowledge of patient-related risk factors for experiencing ARs could be used for electronic risk stratification of patients and thereby allocation of healthcare resources to high risk patients.

Protocols cure diseases, not patients: flaccid paresis in post-NSTEMI statin treatment

An 82-year-old white woman presented at our Internal Medicine ward with flaccid tetraparesis. Two months earlier, she had suffered a non-ST elevation myocardial infarction treated with percutaneous coronary intervention (PCI) and stenting, and she had been prescribed the classical post-PCI therapy (β-blockers, statins and antiplatelet agents). At admission, she was haemodynamically stable and the physical examination revealed reduced reflexes in the four limbs. Urgent laboratory findings revealed mild hypokalaemia. Considering the high statin doses she was taking, we also performed an urgent creatine phosphokinase test, which indicated rhabdomyolysis. Statin therapy was immediately stopped and aggressive fluid treatment begun, supplemented with potassium for increased urinary potassium losses. The patient progressively regained muscle strength.

Optimizing antiretroviral therapy for women living with HIV

PURPOSE OF REVIEW

This review considers the evidence available to guide clinicians in their choice of optimal antiretroviral therapy (ART) for women with HIV.

RECENT FINDINGS

Cohort and clinical trial data indicate that ART is as efficacious in women as men, although women are more likely to discontinue therapy, which compromises effectiveness. For many drugs, women have higher plasma levels than men, although whether this is secondary to differing metabolism in women or because on average women have a lower body mass than men is not clear. For many drugs, women experience more adverse events secondary to ART. Opinion on the use of efavirenz in pregnancy differs between countries. The average age of women with HIV is increasing. Although virological responses to ART are not affected by age, immunological responses may be poorer. Older women with HIV face issues such as neurocognitive impairment, early menopause, osteoporosis and polypharmacy, which will have the potential to impact on their use of ART.

SUMMARY

When planning ART regimes with women, clinicians need to be mindful of the woman's social situation and stage in the life course, as well as the scientific data on individual drug effectiveness according to sex.

Adverse Drug Reactions to Antiretroviral Therapy in HIV-Infected Patients at the Largest Public Hospital in Nicaragua

Objective:

Adverse drug reactions (ADRs) to antiretroviral therapy (ART) are an important cause of hospitalization, treatment discontinuation, and regimen changes in both developed and developing countries. This study is the first to examine and understand ADRs in HIV-infected patients in Nicaragua.

Methods:

A retrospective descriptive study was conducted from May 2010 to March 2011, in a cohort of HIV-infected patients receiving ART at the largest public hospital in Managua, Nicaragua. Patients were identified based on ADRs reporting on a standardized antiretroviral pharmacotherapy form. Subsequently, chart reviews of these patients were performed in order to document the specific ADRs.

Results:

Six hundred ninety-two patients on ART were included. The incidence of ADRs was 6.4% (95% confidence interval [CI] 4.5-8.2). Females demonstrated a higher incidence, that is, 10.2% (95% CI 5.3-15.1, P = .020). Patients treated with combinations of zidovudine (ZDV)/lamivudine (3TC) and emtricitabine (FTC)/tenofovir (TDF) had fewer ADRs ( P < .01) than those using other combinations. Five patients were hospitalized or had a prolonged hospitalization secondary to ADRs, with no mortality attributed to ADR. The most common manifestations of ADRs were central nervous system (20 of 44), gastrointestinal (12 of 44), and dermatologic (8 of 44) reactions. Adverse drug reactions were classified as “likely ADRs” (25 of 44) and “possible ADRs” (19 of 44). No ADRs were preventable.

Conclusion:

Adverse drug reactions most frequently affected the central nervous system. No ADR was life threatening. The frequency of ADRs in this Nicaraguan patient population was less than that reported from other studies in resource-limited settings.

Single centre 20 year survey of antiepileptic drug-induced hypersensitivity reactions

BACKGROUND

Epilepsy is a chronic neurological disease which affects about 1% of the human population. There are 50 million patients in the world suffering from this disease and 2 million new cases per year are observed. The necessary treatment with antiepileptic drugs (AEDs) increases the risk of adverse reactions. In case of 15% of people receiving AEDs, cutaneous reactions, like maculopapular or erythematous pruritic rash, may appear within four weeks of initiating therapy with AEDs.

METHODS

This study involved 300 epileptic patients in the period between September 1989 and September 2009. A cutaneous adverse reaction was defined as a diffuse rash, which had no other obvious reason than a drug effect, and resulted in contacting a physician.

RESULTS

Among 300 epileptic patients of Neurological Practice in Kielce (132 males and 168 females), a skin reaction to at least one AED was found in 30 patients. As much as 95% of the reactions occurred during therapies with carbamazepine, phenytoin, lamotrigine or oxcarbazepine. One of the patients developed Stevens-Johnson syndrome.

CONCLUSION

Some hypersensitivity problems of epileptic patients were obviously related to antiepileptic treatment. Among AEDs, gabapentin, topiramate, levetiracetam, vigabatrin, and phenobarbital were not associated with skin lesions, although the number of patients in the case of the latter was small.

Influence of patient sex and gender on medication use, adherence, and prescribing alignment with guidelines

BACKGROUND

This study evaluates the differences between women and men in medication use, medication adherence, and prescribing alignment with clinical guidelines.

METHODS

We conducted an analysis of pharmacy and medical claims for 29.5 million adults with prescription benefits administered by a pharmacy benefits manager in the United States, age 18 and older, between January 1, 2010, and December 31, 2010. Prevalence and intensity of medication use were evaluated by sex, age group, and medication type (acute vs. chronic). Medication adherence was measured by the percentage of patients with a medication possession ratio (MPR) ≥80%. The percentage of patients receiving guideline-based treatment was measured for diabetes and select cardiovascular conditions.

RESULTS

The study population comprised 16.0 million women and 13.5 million men with continuous pharmacy benefit eligibility. Women were significantly more likely than men to use one or more medications during the analysis period (68% vs. 59%, respectively, p<0.001), and women used more unique medications, on average, than men (5.0 vs. 3.7 medications per year, respectively, p<0.001). Differences in drug utilization were observed for all age groups and medication types. For all clinical metrics evaluated, women were less likely than men to be adherent in their use of chronic medications, and they were less likely to receive the medication treatment and monitoring recommended by clinical guidelines.

CONCLUSIONS

There are significant disparities between women and men in their intensity of medication use, their adherence to medications, and their likelihood of receiving guideline-based drug therapy. These differences may indicate a need for more personalized drug selection and therapeutic management to improve clinical outcomes.

Non-nucleoside reverse transcriptase inhibitors: a review on pharmacokinetics, pharmacodynamics, safety and tolerability

INTRODUCTION

Human immunodeficiency virus (HIV) type-1 non-nucleoside and nucleoside reverse transcriptase inhibitors (NNRTIs) are key drugs of highly active antiretroviral therapy (HAART) in the clinical management of acquired immune deficiency syndrome (AIDS)/HIV infection.

DISCUSSION

First-generation NNRTIs, nevirapine (NVP), delavirdine (DLV) and efavirenz (EFV) are drugs with a low genetic barrier and poor resistance profile, which has led to the development of new generations of NNRTIs. Second-generation NNRTIs, etravirine (ETR) and rilpivirine (RPV) have been approved by the Food and Drug Administration and European Union, and the next generation of drugs is currently being clinically developed. This review describes recent clinical data, pharmacokinetics, metabolism, pharmacodynamics, safety and tolerability of commercialized NNRTIs, including the effects of sex, race and age differences on pharmacokinetics and safety. Moreover, it summarizes the characteristics of next-generation NNRTIs: lersivirine, GSK 2248761, RDEA806, BILR 355 BS, calanolide A, MK-4965, MK-1439 and MK-6186.

CONCLUSIONS

This review presents a wide description of NNRTIs, providing useful information for researchers interested in this field, both in clinical use and in research.

Factors affecting antiretroviral pharmacokinetics in HIV-infected women with virologic suppression on combination antiretroviral therapy: a cross-sectional study

BACKGROUND

Although some studies show higher antiretroviral concentrations in women compared to men, data are limited. We conducted a cross-sectional study of HIV-positive women to determine if protease inhibitor (PI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) C(min) and Cmax values were significantly different than historical general population (predominantly male) averages and to evaluate correlates of higher concentrations.

METHODS

HIV-positive women with virologic suppression (viral load < 50copies/mL) on their first antiretroviral regimen were enrolled. Timed blood samples for C(min) and Cmax were drawn weekly for 3 weeks. The ratio of each individual's median C(min) and Cmax to the published population mean values for their PI or NNRTI was calculated and assessed using Wilcoxon sign-rank. Intra- and inter-patient variability of antiretroviral drug levels was assessed using coefficient of variation and intra-class correlation. Linear regression was used to identify correlates of the square root-transformed C(min) and Cmax ratios.

RESULTS

Data from 82 women were analyzed. Their median age was 41 years (IQR=36-48) and duration of antiretrovirals was 20 months (IQR=9-45). Median antiretroviral C(min) and Cmax ratios were 1.21 (IQR=0.72-1.89, p=0.003) (highest ratios for nevirapine and lopinavir) and 0.82 (IQR=0.59-1.14, p=0.004), respectively. Nevirapine and efavirenz showed the least and unboosted atazanavir showed the most intra- and inter-patient variability. Higher CD4+ count correlated with higher C(min). No significant correlates for Cmax were found.

CONCLUSIONS

Compared to historical control data, C(min) in the women enrolled was significantly higher whereas Cmax was significantly lower. Antiretroviral C(min) ratios were highly variable within and between participants. There were no clinically relevant correlates of drug concentrations.

TRIAL REGISTRATION

NCT00433979.

Non-response in a pharmacy and patient-based intensive monitoring system: a quantitative study on non-response bias and reasons for non-response

Objective

Worldwide pharmacists play an increasingly important role in pharmacovigilance. Lareb Intensive Monitoring (LIM) in the Netherlands is a new form of active pharmacovigilance where pharmacists play a key role. Patients using drugs which are monitored are identified in the pharmacy and invited to participate in the active monitoring. Not all invited patients participate. This study aimed to investigate non-response bias in LIM, as well as reasons for non-response in order to identify barriers to participation.

Methods

The study population consisted of patients who received a first dispensation of an antidiabetic drug monitored with LIM between 1 July 2010 and 28 February 2011. Possible non-response bias was investigated by comparing age, gender and the number of drugs used as co-medication. Reasons for non-response were investigated using a postal questionnaire.

Key findings

Respondents were on average 4.5 years younger than non-respondents and used less co-medication. There were no differences regarding gender. The main reason for non-response was that information in the pharmacy was lacking.

Conclusion

Differences between respondents and non-respondents should be taken into account when analysing and generalising data collected through LIM, as this might contribute to non-response bias. The relatively high response to the postal questionnaire, together with the answers about reasons for non-response, show that patients are willing to participate in a web-based intensive monitoring system, when they are informed and invited in the pharmacy.

Muscular effects of statins in the elderly female: a review

Statins have demonstrated substantial benefits in supporting cardiovascular health. Older individuals are more likely to experience the well-known muscle-related side effects of statins compared with younger individuals. Elderly females may be especially vulnerable to statin-related muscle disorder. This review will collate and discuss statin-related muscular effects, examine their molecular and genetic basis, and how these apply specifically to elderly women. Developing strategies to reduce the incidence of statin-induced myopathy in older adult women could contribute to a significant reduction in the overall incidence of statin-induced muscle disorder in this vulnerable group of patients. Reducing statin-related muscle disorder would likely improve overall patient compliance, thereby leading to an increase in improved short- and long-term outcomes associated with appropriate use of statins.

Women and men report different behaviours in, and reasons for medication non-adherence: a nationwide Swedish survey

Objective

The aim of the present study was to analyse gender differences in self-reported non-adherence (NA) to prescribed medication in the Swedish general population. We aimed to study unintentional and intentional NA as well as the reasons given for NA.

Methods

A questionnaire was mailed to a cross-sectional, random, national sample of people aged 18-84 years in Sweden (n=7985). The response rate was 61.1% (n=4875). The questionnaire covered use of prescription drugs, NA behaviour and reasons for NA.

Results

Use of prescription drugs was reported by 59.5% (n=2802) of the participants, and 66.4% (n=1860) of these participants did not adhere to the prescribed regimen. No overall gender differences in reporting NA were found. However, when analysing the various types of NA behaviour and the reasons for NA, different gender patterns emerged. Men were more likely to report forgetting [OR=0.77 (95%CI 0.65:0.92)], changing the dosage [OR=0.64 (95%CI 0.52:0.79)] and that they had recovered [14.3%, (OR=0.71 (95%CI 0.56:0.90)] as a reason. In contrast, more women than men reported filling the prescription but not taking the drug [OR=1.25 (95%CI 1.02:1.54)] and reported the development of adverse drug reactions (ADRs) [OR=1.89 (95%CI 1.37:2.59)] as a reason more commonly. The gender differences remained, in most cases, after controlling for confounders such as age, socioeconomic factors, medical problems and attitudes toward drugs.

Conclusions

Women and men have different patterns of NA behaviour and different reasons for NA. Therefore, if adherence is to be improved, a wide knowledge of all the reasons for NA is required, along with an understanding of the impact of gender on the outcomes.

Sex-dimorphic adverse drug reactions to immune suppressive agents in inflammatory bowel disease

AIM: To analyze sex differences in adverse drug reactions (ADR) to the immune suppressive medication in inflammatory bowel disease (IBD) patients.

METHODS: All IBD patients attending the IBD outpatient clinic of a referral hospital were identified through the electronic diagnosis registration system. The electronic medical records of IBD patients were reviewed and the files of those patients who have used immune suppressive therapy for IBD, i.e., thiopurines, methotrexate, cyclosporine, tacrolimus and anti-tumor necrosis factor agents (anti-TNF); infliximab (IFX), adalimumab (ADA) and/or certolizumab, were further analyzed. The reported ADR to immune suppressive drugs were noted. The general definition of ADR used in clinical practice comprised the occurrence of the ADR in the temporal relationship with its disappearance upon discontinuation of the medication. Patients for whom the required information on drug use and ADR was not available in the electronic medical record and patients with only one registered contact and no further follow-up at the outpatient clinic were excluded. The difference in the incidence and type of ADR between male and female IBD patients were analyzed statistically by χ² test.

RESULTS: In total, 1009 IBD patients were identified in the electronic diagnosis registration system. Out of these 1009 patients, 843 patients were eligible for further analysis. There were 386 males (46%), mean age 42 years (range: 16-87 years) with a mean duration of the disease of 14 years (range: 0-54 years); 578 patients with Crohn’s disease, 244 with ulcerative colitis and 21 with unclassified colitis. Seventy percent (586 pts) of patients used any kind of immune suppressive agents at a certain point of the disease course, the majority of the patients (546 pts, 65%) used thiopurines, 176 pts (21%) methotrexate, 46 pts (5%) cyclosporine and one patient tacrolimus. One third (240 pts, 28%) of patients were treated with anti-TNF, the majority of patients (227 pts, 27%) used IFX, 99 (12%) used ADA and five patients certolizumab. There were no differences between male and female patients in the use of immune suppressive agents. With regards to ADR, no differences between males and females were observed in the incidence of ADR to thiopurines, methotrexate and cyclosporine. Among 77 pts who developed ADR to one or more anti-TNF agents, significantly more females (54 pts, 39% of all anti-TNF treated women) than males (23 pts, 23% of all anti-TNF treated men) experienced ADR to an anti-TNF agent [P = 0.011; odds ratio (OR) 2.2, 95%CI 1.2-3.8]. The most frequent ADR to both anti-TNF agents, IFX and ADA, were allergic reactions (15% of all IFX users and 7% of all patients treated with ADA) and for both agents a significantly higher rate of allergic reactions in females compared with males was observed. As a result of ADR, 36 patients (15% of all patients using anti-TNF) stopped the treatment, with significantly higher stopping rate among females (27 females, 19% vs 9 males, 9%, P = 0.024).

CONCLUSION: Treatment with anti-TNF antibodies is accompanied by sexual dimorphic profile of ADR with female patients being more at risk for allergic reactions and subsequent discontinuation of the treatment.

Focused DNA microarray analysis for sex-dependent gene expression of drug metabolizing enzymes, transporters and nuclear receptors in rat livers and kidneys

Cytochrome P450(CYP)s are known to show a sexual dimorphic expression in rat livers. However, the comprehensive analysis for the sex-dependent gene expressions of drug metabolizing enzymes except for CYPs, transporters and nuclear receptors in rat livers and kidneys has not been investigated yet. The purpose of the present study was to identify the novel drug metabolizing and pharmacokinetics (DMPK)-related gene(s) which show the sex difference in the mRNA expressions in rat livers and kidneys. Total RNAs were prepared from livers and kidneys in both male and female rats (Crl:CD(SD) and Crlj:WI). A DNA microarray analysis using a "GeneSQUARE Multiple Assay DNA Microarray Drug Metabolism Gene Expression for Rat" was performed. DMPK-related genes which showed sex differences in the mRNA expression were identified in rat livers or kidneys. Especially, the female dominant expressions of UDP glucuronosyltransferase (UGT) s were seen in rat livers and kidneys. The sex difference of UGT expressions in rats might be one of the causal factors of the sex difference of the biological response to UGT substrates.

Representativeness of diabetes patients participating in a web-based adverse drug reaction monitoring system

PURPOSE

Lareb Intensive Monitoring, LIM, is a non-interventional observational cohort method which follows first-time users of certain drugs during a certain period of time and collects information about adverse drug reactions, ADRs. In order for LIM to be a useful pharmacovigilance tool, it is important to know whether the LIM population is comparable to the whole population using the drug. The aim of this study is to compare the LIM diabetes population with an external diabetes reference population on characteristics that may influence the patient's susceptibility for ADRs.

METHODS

In this study, a LIM diabetes population was compared to a reference diabetes population derived from The Groningen Initiative to ANalyse Type 2 diabetes Treatment project. Comparisons were made regarding age, gender, body mass index and polypharmacy, as well as diabetes medication used and disease/treatment duration.

RESULTS

LIM patients were more often men (58.5% vs 50.8%) and in general younger (59.1 vs 64.7 years) and healthier, by that meaning they had a higher percentage of de novo treated patients (55.5% vs 53.2%), a shorter diabetes treatment duration (3.7 vs 5.5 years) and used less co-medication than patients in the reference population.

CONCLUSIONS

This study shows that diabetes patients participating in a web-based intensive monitoring system differ from a reference population. The observed differences might lead to an underestimation of ADRs, but it is not clear whether this would also influence the type or time-course of the reported ADRs. When interpreting results from LIM studies, one should take these differences into account.

[Development and validation of a prediction model to identify HIV+ patients with drug-related problems. A prediction study]

OBJECTIVE

To develop and validate a prediction model for the detection of drug-related problems (DRP) in patients on antiretroviral treatment during their regular monitoring in Pharmaceutical Care Clinics before dispensing drugs. MEHOD: Open multicentre prospective study. HIV patients with and without DRP were included. Demographic, clinical and pharmacotherapy variables (related and unrelated to antiretroviral treatment) were included in the model design. To find prognostic factors for DRP, a binary logistic regression model was created after performing a univariate analysis that identified independent variables related to DRP these variables were introduced in the multivariate model for the final selection. Model validity was determined by the shrinkage method and the discriminatory power by Harrell's C-index.

RESULTS

733 patients were included. The variables "adherence", "prescription of drugs needing dosage adjustment", and "total number of drugs prescribed (apart from the antiretroviral treatment)" were independently related to the appearance of DRP. Probabilities predicted by the model, customising the coefficients using the uniform shrinkage method, showed a R(2)=0.962 for the construction sample and a R(2)=0.872 for the validation sample. The discriminatory capacity of the model was 0.816 for the construction sample and 0.779 for the validation sample.

CONCLUSIONS

The developed and validated model enables detection of patients on antiretroviral treatment who are at a higher risk for experiencing a DRP. The prediction variables employed are commonly used in patient's pharmacotherapy record, allowing the model to be used in routine clinical practice.

Medication-related problems occurring in people with diabetes during an admission to an adult teaching hospital: a retrospective cohort study

AIMS

To examine the characteristics of medication-related problems occurring in people with diabetes admitted to hospital and to identify risk factors for medication-related problems.

METHODS

A retrospective cohort study of medication-related problems occurring in patients admitted to an adult, inner-city Australian teaching hospital was conducted over two-years. The risk factors associated with medication-related problems were identified using random effect logistic regression.

RESULTS

There were 9530 admissions of people with diabetes involving 5205 individuals over a two-year period. Medication-related problems were associated with 686 (7.2%) admissions involving 571 individuals (11.0%). The most common medication-related problems were medication errors (64.1%) associated with hypoglycaemia and unintentional overdose. Five factors were significantly associated with medication-related problems: female gender [odds ratio (OR) 1.30, 95% confidence intervals (CI) 1.11-1.52], age of 18-50 years (OR 2.32, CI 1.85-2.91), single marital status (OR 1.46, CI 1.24-1.74), mental and behavioural problems (OR 1.74, 1.43-2.11), and a comorbidity index score of at least one (OR 1.35-1.67).

CONCLUSIONS

Five significant risk factors were associated with medication-related problems in people with diabetes admitted to hospital. These risks need to be considered when developing care plans and interventions to prevent medication-related problems for individuals with diabetes.

Tolerability aspects in duloxetine-treated patients with depression: Should one use a lower starting dose in clinical practice?

OBJECTIVE

This study questions whether a lower starting dose of duloxetine (DLX) could be beneficial for patients with depression, in terms of tolerability and safety in routine clinical care.

RESEARCH DESIGN AND METHODS

Post-hoc analyses of a multicenter, prospective, non-interventional, 6-month study in adult outpatients with a depressive episode was undertaken.

MAIN OUTCOME MEASURES

Treatment-emergent adverse events (TEAEs), serious adverse events (SAEs), discontinuations due to TEAEs and hospitalizations due to depression, were all documented at 2 weeks, 4 weeks, 3 months and 6 months after treatment initiation/switch to DLX.

RESULTS

Of 4517 patients enrolled, 4313 were included for TEAE evaluation. TEAEs occurred in 17.2% of patients, and SAEs occurred in 0.79% of patients, including one case of suicidal ideation. 1404 patients discontinued within 6 months (TEAEs: n = 119). Starting treatment with 30 mg/day DLX (72.7%) was favored in females, or after inadequate efficacy of previous antidepressant treatment; 60 mg/day DLX was favored in more severe depression and patients receiving concomitant pain medication.

CONCLUSION

Initiating treatment with 60 mg/day DLX was not associated with poorer tolerability in this study. Physicians may be guided by their clinical experience to carefully consider the individual benefit/risk ratio and TEAE susceptibility when deciding to start treatment with a higher or a lower dose of DLX.

Evaluating adverse drug reactions among HAART patients in a resource-constrained province of South Africa

The high prevalence of HIV in KwaZulu-Natal Province, South Africa, has greatly increased the demand for antiretroviral therapy (ART), resulting in an exponential increase in the number of patients initiated on highly active antiretroviral treatment (HAART). However, little information about adverse drug reactions in these patients was forthcoming from public health facilities in KwaZulu-Natal. A compulsory system of reporting adverse drug reactions was established among patients attending accredited ART sites, with minimal resource requirements. The study sought to evaluate the adverse drug reactions reported through the new compulsory system. A retrospective audit was performed on the reporting forms received during the first year of the new system, pertaining to all patients on HAART who had experienced an adverse drug reaction that resulted in a request for a change in antiretroviral (ARV) drug or regimen. The forms for documenting adverse drug reactions were completed by prescribers who would confirm the event or reaction by specifying the diagnosis as well as the relevant clinical and laboratory values. In total, 3 923 forms, submitted between 1 May 2007 and 31 May 2008, were available for audit. Adverse drug reactions were documented in 78.7% of the reports and 74% of the patients that presented with an adverse event were females. Of the forms recording a serious adverse drug reaction, 84.7% pertained to patients taking the three-drug combination stavudine, lamivudine and either efavirenz or nevirapine. Of those reports, stavudine was implicated as the possible causative agent of an adverse drug reaction in 93% of the cases. In 73.6% of the total reports the proposed new regimen was zidovudine, lamivudine and efavirenz or nevirapine. The compulsory system of reporting greatly improved the reporting of adverse drug reactions associated with HAART among patients in the province. This system may be similarly implemented in other low-resourced settings to actively encourage the reporting of adverse drug reactions associated with ARV use.

Rash in psychiatric and nonpsychiatric adolescent patients receiving lamotrigine in Korea: a retrospective cohort study

OBJECTIVE

Lamotrigine is a widely used medication for psychiatric disorders and epilepsy, but the adverse effects of this drug in adolescent Korean patients have not yet been investigated. In the present study, we sought to compare the incidence and impact of lamotrigine-induced skin rashes and different pattern of adverse events in psychiatric and nonpsychiatric adolescent patients.

METHODS

Using a retrospective cohort design, all of the charts were reviewed for adolescents (13 to 20 years old), treated with lamotrigine during the previous 2 years in the Child and Adolescent Psychiatric Clinic and Pediatric Neurologic Clinic of the Ulsan University Hospital in South Korea.

RESULTS

Of the 102 subjects, 23 patients developed a skin rash. All of these rashes were observed within 7 weeks of the initiation of the lamotrigine therapy. Only one subject developed a serious rash, which was diagnosed as Stevens-Johnson syndrome. Although the psychiatric subjects were administered statistically lower doses of lamotrigine during weeks 1 through 5 and at week 12, the likelihood of developing a rash was not significantly different between the psychiatric and nonpsychiatric patients.

CONCLUSION

Careful dose escalation and close observation of side effects for the first 7 weeks of treatment is important. The present study reveals the tolerability of lamotrigine in an adolescent population, although a double-blind, controlled trial is needed to confirm these findings.

Gene, ethnic and gender influences predisposition of adverse drug reactions to artesunate among Malaysians

CONTEXT

Artesunate (AS) and amodiaquine (AQ) are two prodrugs widely used as antimalarial agents and are metabolized by the CYP P450 2A6 (CYP 2A6) and CYP P450 2C8 (CYP 2C8) enzymes, respectively.

OBJECTIVE

In this study, we aim to investigate the association of both genes on AS and AQ's tolerabilities in the hope of identifying a pharmacogenetic approach that could be useful in prediction and prevention of adverse drug reactions (ADRs) among Malaysian population.

MATERIALS AND METHODS

In this randomized crossover study, loose and AS/AQ formulations were administered to normal healthy volunteers (n = 24) over two study phases. The drugs' tolerabilities (incidence of facial flushing, giddiness, headache, nausea, abdominal discomfort, progression of liver enzymes and neutrophil counts) were compared between the two treatment arms. Volunteers were also genotyped for the CYP2C8 and CYP2A6 variants.

RESULTS

The frequency of the CYP2A6*1B, CYP2A6*4, CYP2A6*8 and CYP2A6*9 alleles were 54.2%, 16.7%, 4.2% and 10.4%, respectively. No mutations for CYP2C8 gene were, however, detected. Most (96%) of the subjects were of the Malay ethnicity. Subjects having the CYP2A6*1B variants responsible for ultra rapid metabolism of AS suffered a significantly higher incidence of ADRs.

DISCUSSION

Our study is the first to report that CYP2A6 genotyping influences AS's ADR. Gender also plays a role where females reported more incidences of nausea (p < 0.05).

CONCLUSION

It is concluded that genetic polymorphisms of CYP2A6 as well as gender influence the side effect profiles of subjects receiving AS among this Malaysian population.

Tissue distribution and gender-divergent expression of 78 cytochrome P450 mRNAs in mice

Cytochrome P450 (Cyp) enzymes from the first four families (Cyp1-4) play a major role in metabolizing xenobiotics, affecting drug pharmacokinetics and chemical-induced toxicity. Due to cloning of the mouse genome, many novel Cyp isoforms have been identified, but their tissue distribution of expression is unknown. This study compared the tissue distribution of all 78 Cyps from the Cyp1-4 families in C57BL/6 mice providing not only an indication of which tissues novel Cyps may have their greatest importance but also a cohesive comparison of the tissue distribution of all Cyp1-4 isoforms. Transcripts of the 78 Cyps were quantified by multiplex suspension arrays and quantitative real-time PCR in 14 tissues. Hierarchical clustering indicated that in male mice, 52% of the Cyp species were expressed highest in liver, 10% in kidney, 10% in duodenum/jejunum, 10% in testes, 5% in lung, and < 4% in colon, brain, heart, and stomach. Female mice had a similar pattern of Cyp messenger RNA expression; however, compared with males, females had 7% more Cyps that were liver predominant, 2% more Cyps that were stomach predominant, but 1% less Cyps that were kidney and lung predominant. Differences in gender expression were observed in 29 of the Cyps, with 24 being higher in females than males. Additionally, the data suggest a correlation between the spatial arrangement of genes within a gene cluster and their organ-predominant expression, indicating a common regulatory mechanism may be present within these clusters. In conclusion, this study provides novel data on the tissue distribution and gender-divergent expression of 78 functional mouse Cyp isoforms.

Sex and sensitivity: the continued need for sex-based biomedical research and implementation

The phrase 'women's health research' embraces women as part of the biomedical research engine while categorizing women as separate. Before personalized medicine can become a reality, we must first ensure that basic physiological differences between the sexes are clearly delineated. In this article we argue that research into sex differences should be encouraged at the most fundamental levels of the biomedical sciences. Moreover, appropriate representation of both sexes as participants in clinical studies is still critically needed. Academic and governmental organizations must continue to articulate strong policy in order to ensure inclusion and analysis of sex as a critical variable. Focused attention on sex as a contributing factor to health, disease and therapeutic activity will increase our fund of knowledge regarding our everyday health, increase the pace of clinical research and ensure a healthier population.

Ethnicity and gender differences in lipodystrophy of HIV-positive individuals taking antiretroviral therapy in Ontario, Canada

PURPOSE

This study assessed ethnicity and gender differences in prevalence, type, and severity of antiretroviral-associated lipodystrophy in HIV-positive individuals in Ontario.

METHODS

This was a cross-sectional analysis of the Ontario Cohort Study (OCS), a prospective study of HIV-positive patients in Ontario. Lipodystrophy was defined as at least 1 major or 2 minor self-reported changes of peripheral lipoatrophy and/or central lipohypertrophy. Prevalence, type, and severity were compared by ethnicity (Black, White, or Other) and gender. Univariate and multivariate logistic regression analyses identified predictors of lipodystrophy.

RESULTS

Data were available for 778 participants (659 men, 119 women). There were 517 Whites, 121 Blacks, and 140 patients of Other ethnicities. In univariate analyses, Whites reported more peripheral lipoatrophy (P = .004) and abdominal lipohypertrophy (P = .04); these ethnic differences were observed in males (P = .05 and P = .03, respectively) but not females. Males reported more peripheral lipoatrophy (P = .01), whereas females had more central lipohypertrophy (P < .0001) and mixed fat redistribution (P < .0001). Multivariable regression analyses revealed Black women to be most vulnerable to lipodystrophy (P = .02), particularly lipohypertrophy (P < .0001).

CONCLUSIONS

Ethnicity and gender are important factors influencing lipodystrophy. Combining lipoatrophy and lipohypertrophy into a single entity is not appropriate. Black women were most vulnerable to lipohypertrophy, which has important implications for antiretroviral therapy roll-out in Africa.

Sex differences in drug disposition

Physiological, hormonal, and genetic differences between males and females affect the prevalence, incidence, and severity of diseases and responses to therapy. Understanding these differences is important for designing safe and effective treatments. This paper summarizes sex differences that impact drug disposition and includes a general comparison of clinical pharmacology as it applies to men and women.

Adverse drug reactions in medical intensive care unit of a tertiary care hospital

PURPOSE

Patients in the intensive care unit (ICU) have multiorgan dysfunction as well as altered pharmacokinetic parameters. Hence they are susceptible to adverse drug reactions (ADRs). The objective of the study is to assess the characteristics of ADRs among inpatients in the medical ICU and to compare the same with patients who have not experienced ADRs.

METHODS

Prospective, observational study for a period of 1 year in medical ICU of a tertiary care hospital. Relevant data of patients with ADRS were analysed. Characteristics of patients with and without ADRs were compared.

RESULTS

Of 728 patients admitted in medical ICU, 222 (28.4%) had ADRs. Multiple ADRs (38.7%) implicated by the same drug and serious ADRs (37%) were noticed. Renal/electrolyte system (21%) was most commonly involved. Clinical spectrum included acute renal failure (ARF, 11.4%), hepatic injuries (5.4%), haematological dysfunction (4.2%), seizures (3.3%), upper gastrointestinal bleed (3.3%) and cutaneous ADRs (3.3%). Antimicrobials (27%) were the commonly implicated drug class. The most commonly implicated drug was furosemide (6.8%). Infrequently reported ADRs included azithromycin-induced erythema multiforme, leflunamide-induced erythema multiforme and vasculitis, ceftazidime-induced seizures and ceftriaxone-induced hepatitis. Co-morbidity, polypharmacy and duration of stay were significantly higher in patients with ADRs compared to those who have not experienced ADRs. Three patients died.

CONCLUSION

High incidence of serious and multiple ADRs noticed. A wide clinical spectrum of ADRs and infrequently reported ADRs to newer drugs were also observed.

Risk analysis of severe myelotoxicity with temozolomide: the effects of clinical and genetic factors

A benefit of temozolomide (TMZ) is that myelotoxicity is uncommon. Recently, several small series have reported significant myelotoxicity resulting in treatment delays or death. The ability to predict risk of myelotoxicity may influence patient care. We retrospectively reviewed 680 malignant glioma patients and developed a clinical risk formula for myelotoxicity for each gender by logistic regression. The variables that remained were assigned a score of 1 and added together for a final risk score. Women experienced more myelotoxicity than did men (p = 0.015). For males, risk factors included body surface area (BSA) > or = 2 m(2) (odds ratio [OR] = 2.712, p = 0.04), not on steroids (OR = 2.214, p = 0.06), and on bowel medication (OR = 3.955, p = 0.008). For females, final factors included no prior chemotherapy (OR = 3.727, p = 0.001), creatinine > or = 1 mg/dl (OR = 6.08, p = 0.002), platelets < 270,000/mm(3) (OR = 2.438, p = 0.03), BSA < 2 m(2) (OR = 4.178, p = 0.04), not on medication for gastroesophageal reflux disease (OR = 2.942, p = 0.01), and on analgesics (OR = 2.169, p = 0.05). Age was included because of observable trends. Risk of developing myelotoxicity ranged from 0% to 33% (male) and from 0% to 100% (females). Polymorphisms in NQO1 (NAD(P)H dehydrogenase, quinone 1), MGMT (O(6)-methylguanine-DNA methyltransferase), and GSTP1 (glutathione S-transferase pi 1) were related to risk of developing myelotoxicity in a subset of patients. Myelotoxicity with TMZ is a significant clinical issue for those at risk. Use of a clinical model to predict risk and evaluation of identified genetic polymorphisms related to myelotoxicity may allow for individualized dosing, optimizing patient management.

A pharmacovigilance study in medicine department of tertiary care hospital in chhattisgarh (jagdalpur), India

The aim of the present study was to observe adverse drug reactions (ADRs) with respect to polypharmacy at tertiary care centre at Bastar, Jagdalpur (Government Medical College, Jagdalpur). A prospective, observational evaluation of the ADRs conducted over a period of 6 months in Department of Medicine in Government Medical College, Jagdalpur. During the study period, a total of about 4850 patients visited the OPD and inpatient ward of medicine department, and 154 ADRs events were reported. Out of 154 reports that were identified, a higher percentage of ADRs in females (51.29%) was observed as compared to males (48.7%). Of the 154 ADRs, 76 (49.35%) were found to be mild, 55 moderate (35.71%), and 23 severe (14.93%). A total of 99 (64.28%) ADRs were observed in patients receiving four or more medications concurrently. Conversely 55 (35.71%) ADRs were detected in patients using three or less medicines. The largest number of reports was associated with antimicrobial therapy (28.57%), followed by antihypertensive (24.02%) and antidiabetics (14.28%). Among the affected organ systems, gastrointestinal ADRs constituted a major component (39.61%) followed by skin reactions (28.57%). On causality assessment, nearly 36.36% ADRs were considered as probable, 31.16% possible, and 9.74% could not be categorized and were placed under unassessable. Expected, limited ADR are permissible in normal clinical setting, but the present study focuses on the result showing increased and amplified ADR associated with the polypharmacy practices, which may be curtailed with rational drug prescribing habit.

Sex-specific differences in side effects of psychotropic drugs: genes or gender?

Sex differences observed in the adverse effects associated with psychotropic drugs have not been reported consistently in the literature. In this review, we discuss the current published data on sex differences observed in the occurrence, symptomatology and reporting of the adverse effects associated with psychotropic drug effects, and discuss their clinical relevance. We reviewed the published data up to April 2009 on sex differences in the side effects of antipsychotics, antidepressant and mood stabilizers, by systematically searching PubMed using combinations of search terms and retrieving relevant references specifically reporting on these issues. The majority of the data was retrieved from clinical studies where the main outcome parameters did not relate specifically to sex differences. In most instances, sex was associated with other factors influencing side effects such as age, disease and body weight. Sex-related differences were reported in the side effects associated with antipsychotic drug-induced weight gain and metabolic syndrome, symptoms of sexual dysfunction caused by antidepressants and antipsychotic drugs and cardiac arrhythmic side effects associated with antipsychotic drugs. Women might differ from men not only in incidence but also in the presentation of clinical symptoms associated with adverse psychotropic drug effects. Clinicians should be made aware of the differences reported in the literature regarding the symptomatology, severity and recognition of the adverse psychotropic drug effects found in men and women.

Treatment of anemia among women with chronic kidney disease in United States outpatient settings

AIMS

Women with chronic kidney disease (CKD) are often at risk for anemia. This study examined variations in anemia care and management among women with CKD in outpatient settings in the United States.

METHODS

The study utilized National Ambulatory Medical Care Survey (NAMCS) data from 1996 to 2003. Women aged 18 years or older with CKD were included based on ICD-9-CM codes for CKD, anemia, and reason for visit. Anemia-related medications were retrieved using NAMCS drug codes.

RESULTS

Approximately 58 million weighted outpatient visits for women with CKD were made. Nearly 14% of these visits were by Hispanic women and 50% visits were by patients aged 65 years or older. Nephrologists accounted for only 15% of CKD patient visits and 51% of these patients had anemia diagnosis. Additionally, 32% of patients were using 5 or more medications. Women with Medicare coverage were 2.6 times more likely (p < .05) to be diagnosed with anemia by a nephrologist and were 2.4 times more likely (p < .05) to receive a prescription to treat anemia than patients seen by non-nephrologists. Hispanic women were 56% less likely (p < or = .05) to use 5 or more medications than non-Hispanic patients. CKD patients with anemia diagnosis were 50% less likely to receive 5 or more medications (p < or = .05).

CONCLUSION

This study found many risk factors associated with the diagnosis and treatment of anemia in women with CKD being treated in U.S. outpatient settings. Increased awareness of early treatments for anemia and assessments of patients receiving multiple medications is needed in women with CKD.

Sex differences in blood pressure response to antihypertensive therapy in Chinese patients with hypertension

BACKGROUND

Sex-specific responses to antihypertensive drugs are not very well understood.

OBJECTIVE

To investigate sex-related differences in blood pressure response to antihypertensive drugs in a community-based prospective clinical trial.

METHODS

We recruited 3535 untreated hypertensive patients (2326 women), aged 40-75 years, from 7 rural communities in China. Subjects were randomized to 1 of 4 drug groups: atenolol, hydrochlorothiazide (HCTZ), captopril, or sustained-released nifedipine; duration of the study was 8 weeks. Mean blood pressure reduction, blood pressure control rates, and frequency of adverse events were compared between men and women.

RESULTS

Women had a better response to HCTZ in relation to diastolic blood pressure (1.8 mm Hg lower) than did men (p < 0.05) and were 57% more likely to reach the control goal of diastolic blood pressure than were men (p < 0.05). In the atenolol group, mean systolic blood pressure decreased 3.9 mm Hg more in women than in men (p < 0.05), and women were 65% more likely to reach the control goal of systolic blood pressure and 57% more likely to reach the control goal of diastolic blood pressure than were men (p < 0.05). Significant sex-related differences were also found in drug-related adverse events in the nifedipine group (15.8% in women vs 9.8% in men; p = 0.017) and in the captopril group (14.3% in women vs 8.4% in men; p = 0.005), but no differences were seen with HCTZ or atenolol.

CONCLUSIONS

Women have better blood pressure responses to HCTZ and atenolol and experience more adverse effects with sustained-release nifedipine and captopril than do men, indicating that sex should be taken into account when selecting antihypertensive drugs.

Adverse drug reactions as a cause of hospital admissions: a 6-month experience in a single center in Greece

BACKGROUND

Adverse drug reactions (ADRs) are a significant cause of morbidity and mortality.

METHODS

A prospective study was conducted over a 6-month period. All patients consecutively admitted were enrolled in the study. Analysis included: (1) an evaluation of the frequency of ADR-related hospital admissions and their causality, severity, and preventability; (2) a description of the type of drugs involved; (3) a report of the most common clinical manifestations related to these ADRs; and (4) an assessment of the factors that were predictive of ADRs.

RESULTS

Seventy of the 548 admissions (12.8%) were related to an ADR. Hemorrhage represented the most common ADR (37.3%), followed by metabolic and renal events (10.8% each). The drugs most often involved were non-steroid anti-inflammatory drugs (NSAIDs), followed by diuretics, aspirin, oral anticoagulants, and oral hypoglycemic agents. A comparison between ADR and non-ADR-related admissions showed that mean number of medications and age were significantly higher for patients admitted for an ADR than for those who were not. Gender, chronic disease at admission, days of hospitalization, cognitive impairment, renal insufficiency, physical activity impairment, and use of psychoactive drugs did not differ between the two groups. In the multivariate analysis, number of drugs was the only independent predictor of ADR-related hospital admission (OR=1.064, 95% CI 1.019-1.109). In 13 of 70 (18.6%) ADR-related hospital admissions, ADRs were coded as severe.

CONCLUSIONS

ADRs are common causes of hospital admissions and may have important consequences. The most important determinant for ADR-related hospital admissions is the number of drugs taken.