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Qiu J, Huang X, Kuang M, Wang C, Yu C, He S, Xie G, Wu Z, Sheng G, Zou Y. Evaluating the prognostic value of systemic immune-inflammatory index in patients with acute decompensated heart failure. ESC Heart Fail 2024; 11:3133-3145. [PMID: 38867498 DOI: 10.1002/ehf2.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 06/14/2024] Open
Abstract
AIMS The value of the systemic immune-inflammatory index (SII) in assessing adverse outcomes in various cardiovascular diseases has been extensively discussed. This study aims to evaluate the predictive value and risk stratification ability of SII for 30 day mortality in patients with acute decompensated heart failure (ADHF). METHODS This analysis included 1452 patients hospitalized for ADHF, all the participants being part of the China Jiangxi-acute decompensated heart failure1 project. The risk stratification capability of the SII in patients with ADHF, as well as its correlation with the 30 day mortality risk among ADHF patients, was evaluated utilizing Kaplan-Meier survival analysis and multivariable Cox regression models. A restricted cubic spline was employed to model the dose-response relationship between the two, and the receiver operating characteristic curve was utilized to assess the predictive ability of SII for 30 day mortality. RESULTS The Kaplan-Meier analysis revealed that the risk of mortality in the high SII group (SII ≥ 980 × 109/L) was significantly greater than that in the low SII group (SII < 980 × 109/L, log-rank P < 0.001). After adjusting for various confounding factors, a higher SII was associated with an increased risk of 30 day mortality in ADHF patients [hazard ratio (HR) = 2.03, 95% confidence interval (CI): 1.34-3.08]. Further restricted cubic spline analysis revealed a non-linear dose-response relationship between the two (P for non-linear = 0.006). Receiver operating characteristic analysis demonstrated that SII had a high accuracy in predicting 30 day mortality events in ADHF patients (AUC = 0.7479), and the optimal predictive threshold was calculated to be 980 × 109/L, a sensitivity of 0.7547 and a specificity of 0.7234. CONCLUSIONS This study found a significant positive association between SII and 30 day all-cause mortality in ADHF patients. We determined the SII cut-off point for predicting 30 day all-cause mortality in patients with ADHF to be 980 × 109/L.
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Affiliation(s)
- Jiajun Qiu
- Jiangxi Medical College, Nanchang University, Nanchang, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Xin Huang
- Jiangxi Medical College, Nanchang University, Nanchang, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Maobin Kuang
- Jiangxi Medical College, Nanchang University, Nanchang, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Chao Wang
- Jiangxi Medical College, Nanchang University, Nanchang, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Changhui Yu
- Jiangxi Medical College, Nanchang University, Nanchang, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Shiming He
- Jiangxi Medical College, Nanchang University, Nanchang, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Guobo Xie
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Zhiyong Wu
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Guotai Sheng
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
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Korupolu R. Intrathecal baclofen therapy for spasticity in a person with spinal cord injury and end-stage renal disease dependent on hemodialysis: a case report. Spinal Cord Ser Cases 2024; 10:51. [PMID: 39069535 DOI: 10.1038/s41394-024-00666-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/10/2024] [Accepted: 07/18/2024] [Indexed: 07/30/2024] Open
Abstract
INTRODUCTION Spasticity is one of the most common secondary complications following a spinal cord injury (SCI), which can significantly debilitate a patient irrespective of the severity of the injury. Intrathecal baclofen therapy can effectively reduce global spasticity in bilateral lower extremities at lower doses and allows precise dose titration to manage spasticity optimally. In complex patients with spasticity and multiple medical comorbidities, multidisciplinary teamwork is required to assess ITB safety and deliver timely intervention to prevent secondary complications of spasticity and improve quality of life. CASE PRESENTATION A 61-year-old African American male with multiple comorbidities, including end-stage renal disease (ESRD) requiring dialysis sustained non-traumatic SCI due to epidural abscess resulting in paraplegia and severe debilitating spasticity. Spasticity gradually worsened and interfered with his ability to achieve independence with functional activities appropriate for his neurological level of injury. A multidisciplinary team approach in this complex case resulted in a successful ITB trial and subsequent ITB implantation, resulting in reduced spasticity and improved quality of life. To our knowledge, this is the first case report of the administration of intrathecal baclofen pump therapy in a person with SCI and end-stage renal disease (ESRD) dependent on hemodialysis. DISCUSSION ITB therapy can be safely delivered in a person with SCI and multiple medical comorbidities, including ESRD, dependent on hemodialysis to manage spasticity. However, a careful evaluation and discussion among the multidisciplinary team managing the patient's morbidities and patient is required to assess the risks and benefits of ITB therapy to allow the patient to make an informed decision.
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Affiliation(s)
- Radha Korupolu
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX, USA.
- TIRR Memorial Hermann, Houston, TX, USA.
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Muanda FT, Weir MA, Ahmadi F, McArthur E, Sontrop JM, Abdullah SS, Urquhart BL, Sadeghi H, Kim RB, Garg AX. Thirty-day risk of digoxin toxicity among older adults co-prescribed trimethoprim-sulfamethoxazole versus amoxicillin: A population-based cohort study. Pharmacotherapy 2024; 44:558-569. [PMID: 38922947 DOI: 10.1002/phar.2948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
IMPORTANCE Trimethoprim-sulfamethoxazole (TMP-SMX) may increase digoxin concentration, a medication with a narrow therapeutic index. Small changes in digoxin concentration could predispose individuals to the risk of toxicity. OBJECTIVE To characterize the risk of digoxin toxicity in older adults taking digoxin following co-prescription of TMP-SMX compared with co-prescription of amoxicillin. DESIGN, SETTINGS, AND PARTICIPANTS Retrospective population-based cohort study in Ontario, Canada (2002-2020) using linked health care data. Participants comprised 47,961 older adults taking digoxin (58% women; median age 80 years [interquartile range 74-86]) who were newly treated with TMP-SMX (n = 10,273) compared with those newly treated with amoxicillin (n = 37,688). EXPOSURE Co-prescription of TMP-SMX versus amoxicillin in older adults concurrently taking digoxin. MAIN OUTCOME AND MEASURE The primary outcome was a hospital encounter (i.e., hospital admission or emergency department visit) with digoxin toxicity within 30 days of the antibiotic prescription. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on indicators of baseline health. Weighted risk ratios (RR) were obtained using modified Poisson regression and weighted risk differences (RD) using binomial regression. The number needed to harm (NNH) was calculated as 1/RD. RESULTS A hospital encounter with digoxin toxicity occurred in 49/10,273 (0.48%) patients treated with TMP-SMX versus 32/37,688 (0.08%) in those treated with amoxicillin (weighted RR, 5.71 [95% confidence interval (CI), 3.19 to 10.24]; weighted RD, 0.39% [95% CI, 0.25% to 0.53%]; NNH 256 [95% CI, 233 to 400]). CONCLUSION AND RELEVANCE In older adults taking digoxin, the 30-day risk of a hospital encounter with digoxin toxicity was nearly 6 times higher in those co-prescribed TMP-SMX versus amoxicillin, although the absolute risk difference was low (0.4%). Physicians should prescribe an alternative antibiotic when clinically appropriate. If TMP-SMX must be co-prescribed with digoxin (if the benefit is believed to outweigh the risk), digoxin should be dose-reduced on an individual basis.
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Affiliation(s)
- Flory T Muanda
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Matthew A Weir
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Fatemeh Ahmadi
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Eric McArthur
- ICES Western, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Jessica M Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Sheikh S Abdullah
- ICES Western, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Brad L Urquhart
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Hasti Sadeghi
- Department of Biology, Western University, London, Ontario, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
| | - Amit X Garg
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
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Qiu J, Huang X, Kuang M, Yang R, Li J, Sheng G, Zou Y. Lipoprotein Combine Index as a Better Marker for NAFLD Identification Than Traditional Lipid Parameters. Diabetes Metab Syndr Obes 2024; 17:2583-2595. [PMID: 38946912 PMCID: PMC11214567 DOI: 10.2147/dmso.s462181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/20/2024] [Indexed: 07/02/2024] Open
Abstract
Purpose The association between traditional lipid parameters and non-alcoholic fatty liver disease (NAFLD) has been extensively discussed. This study aims to evaluate and compare the lipoprotein combine index (LCI) and traditional lipid parameters [total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C)] to identify NAFLD. Patients and Methods The analysis included 14,251 participants from the NAfld in the Gifu Area, Longitudinal Analysis (NAGALA). Logistic regression models were employed to calculate standardized odds ratios (ORs) and 95% confidence intervals (CIs) for assessing and comparing the association of LCI and traditional lipid parameters with NAFLD. Additionally, receiver operating characteristic (ROC) curves were used to calculate the area under the curve (AUC) for LCI and traditional lipid parameters in identifying NAFLD. Results After adjusting for various confounders, we found that LCI was positively associated with NAFLD (OR=2.25, 95% CI 1.92-2.63), and this association was stronger than that of traditional lipid parameters [OR: TC1.23, TG1.73 LDL-C1.10]. Further subgroup analyses revealed that the association of LCI with NAFLD was stronger than other traditional lipid parameters in all subgroups, including men and women, overweight/obese [body mass index (BMI)≥25 kg/m2] and non-obese (BMI<25 kg/m2), and older (age≥45 years) and younger (age<45 years) participants. Additionally, ROC analysis indicated that LCI (AUC=0.8118) had significantly higher accuracy (All DeLong P<0.05) in identifying NAFLD compared to traditional lipid parameters (AUC: TC0.6309; TG0.7969; LDL-C0.6941); HDL-C0.7587). Sensitivity analysis further confirmed the robustness of the study findings. Conclusion This study revealed for the first time a positive correlation between LCI and NAFLD. Compared to traditional lipid parameters, LCI has a higher correlation with NAFLD. Additionally, further ROC analysis demonstrated that LCI had higher accuracy in identifying NAFLD compared to traditional lipid parameters, suggesting that LCI may be a better marker for NAFLD identification than traditional lipid parameters.
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Affiliation(s)
- Jiajun Qiu
- Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi Province, People’s Republic of China
- Jiangxi Cardiovascular Research Institute, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, People’s Republic of China
| | - Xin Huang
- Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi Province, People’s Republic of China
- Jiangxi Cardiovascular Research Institute, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, People’s Republic of China
| | - Maobin Kuang
- Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi Province, People’s Republic of China
- Jiangxi Cardiovascular Research Institute, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, People’s Republic of China
| | - Ruijuan Yang
- Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
- Department of Endocrinology, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi Province, People’s Republic of China
| | - Jiachong Li
- Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Guotai Sheng
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi Province, People’s Republic of China
- Jiangxi Provincial Geriatric Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, People’s Republic of China
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi Province, People’s Republic of China
- Jiangxi Cardiovascular Research Institute, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, People’s Republic of China
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Lu S, Wang Q, Lu H, Kuang M, Zhang M, Sheng G, Zou Y, Peng X. Lipids as potential mediators linking body mass index to diabetes: evidence from a mediation analysis based on the NAGALA cohort. BMC Endocr Disord 2024; 24:66. [PMID: 38730299 PMCID: PMC11083816 DOI: 10.1186/s12902-024-01594-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Body mass index (BMI) and lipid disorders are both known to be strongly associated with the development of diabetes, however, the indirect effect of lipid parameters in the BMI-related diabetes risk is currently unknown. This study aimed to investigate the mediating role of lipid parameters in the association of BMI with diabetes risk. METHODS We assessed the association of diabetes risk with BMI, as well as lipid parameters including high-density lipoprotein cholesterol(HDL-C), low-density lipoprotein cholesterol(LDL-CF and LDL-CS), triglycerides(TG), total cholesterol(TC), remnant cholesterol(RC), non-HDL-C, and combined indices of lipid parameters with HDL-C (RC/HDL-C ratio, TG/HDL-C ratio, TC/HDL-C ratio, non-HDL/HDL-C ratio, LDL/HDL-C ratio) using data from 15,453 subjects in the NAGALA project. Mediation models were used to explore the mediating role of lipid parameters in the association of BMI with diabetes risk, and mediation percentages were calculated for quantifying the strength of the indirect effects. Finally, receiver operating characteristic curve (ROC) analysis was used to compare the accuracy of BMI and BMI combined with lipid parameters in predicting incident diabetes. RESULTS Multivariate regression models, adjusted for confounding factors, demonstrated robust associations of lipid parameters, BMI, with diabetes risk, with the exception of TC, LDL-CF, LDL-CS, and non-HDL-C. Mediation analysis showed that lipid parameters except TC, LDL-CF, LDL-CS, and Non-HDL-C were involved in and mediated the association of BMI with diabetes risk, with the largest mediation percentage being the RC/HDL-C ratio, which was as high as 40%; it is worth mentioning that HDL-C and HDL-C-related lipid ratio parameters also play an important mediating role in the association between BMI and diabetes, with the mediator proportion being greater than 30%. Finally, based on the ROC results, we found that the prediction performance of all lipid parameters in the current study except TC was significantly improved when combined with BMI. CONCLUSION Our fresh findings suggested that lipid parameters partially mediated the association of BMI with diabetes risk; this result indicated that in the context of diabetes risk screening and disease management, it is important to not only monitor BMI but also pay attention to lipid parameters, particularly HDL-C and HDL-C-related lipid ratio parameters.
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Affiliation(s)
- Song Lu
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Qun Wang
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, China
| | - Hengcheng Lu
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, China
| | - Maobin Kuang
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, China
| | - Min Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
- Jiangxi Hypertension Research Institute, Nanchang, 330006, China
| | - Guotai Sheng
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, China
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, China.
| | - Xiaoping Peng
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China.
- Jiangxi Hypertension Research Institute, Nanchang, 330006, China.
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Killam-Worrall L, Brand R, Castro JR, Patel DS, Huynh K, Lindley B, Torres BP. Baclofen and Tizanidine Adverse Effects Observed Among Community-Dwelling Adults Above the Age of 50 Years: A Systematic Review. Ann Pharmacother 2024; 58:523-532. [PMID: 37589096 DOI: 10.1177/10600280231193080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE This review highlights adverse effects of baclofen and tizanidine in older community-dwelling adults. DATA SOURCES A literature search was conducted, including search terms of "adverse effect," "baclofen," "elderly," "falls," "fractures," and "tizanidine." Studies were included if they described community-dwelling adults aged 50 years and older who received oral baclofen or tizanidine. The Federal Drug Administration Adverse Event Reporting System (FAERS) data were compiled for adverse effect incidence. STUDY SELECTION AND DATA EXTRACTION The literature search was completed in July 2019 and updated in June 2023. Reviews performed by 2 independent reviewers yielded 15 records. FAERS identified 486 (baclofen) and 305 (tizanidine) adverse effects of interest. DATA SYNTHESIS Two retrospective cohort studies evaluating baclofen use in older adults showed increased hospitalizations for encephalopathy in chronic kidney disease (7.2% vs 0.1%) and end-stage renal disease (daily dose 20 mg or more; relative risk [RR] 19.8, 95% CI = [14.0-28.0]). Other articles were case reports; 10 articles reported dyskinesias, encephalopathy or disorientation, and drowsiness associated with baclofen, and 5 articles reported bradycardia and/or hypotension with tizanidine. The FAERS Public Dashboard revealed 12.1% and 28.7% overall incidence of adverse effects of interest, with a 27.8% and 29.2% incidence of falls for baclofen and tizanidine, respectively. Baclofen and tizanidine are associated with concerning adverse effects in older adults. Alternative agents should be considered, but, if necessary, providers should start at lower doses and increase slowly. CONCLUSIONS This review highlights the importance of using baclofen and tizanidine with caution in older adults.
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Affiliation(s)
- Lisa Killam-Worrall
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
| | - Romana Brand
- Wise Regional Health System Emergency Department, Decatur, TX, USA
| | | | | | | | - Bryn Lindley
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
| | - Brittany Palasik Torres
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
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Hu C, Yu Z, Wei C, Sheng G, Chen J, Zou Y. Evaluating the relative importance of different blood pressure indices in screening for NAFLD: a survey report based on a health examination population. Front Cardiovasc Med 2024; 11:1338156. [PMID: 38742174 PMCID: PMC11089114 DOI: 10.3389/fcvm.2024.1338156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 04/18/2024] [Indexed: 05/16/2024] Open
Abstract
Objective While hypertension is a well-recognized risk factor for non-alcoholic fatty liver disease (NAFLD), the specific roles of various common blood pressure measurements [diastolic blood pressure (DBP), systolic blood pressure (SBP), pulse pressure (PP), mean arterial pressure (MAP)] in detecting NAFLD and evaluating the associated risk in adults remain unclear. Methods A retrospective analysis was conducted on 14,251 adult participants undergoing health screenings in the NAfld in the Gifu Area, Longitudinal Analysis project (NAGALA). Following the Z-transformation of the independent variables, we evaluated the relationships between the four blood pressure indices and NAFLD through multivariable logistic regression models. This analysis documented the odds ratio (OR) and 95% confidence interval (CI) for each standard deviation (SD) increase. Additionally, the effectiveness of these indices in identifying NAFLD was comparatively analyzed using receiver operating characteristic (ROC) curves. Results After adequately adjusting for confounders, all blood pressure indices except PP showed a positive correlation with NAFLD. For each SD increment, MAP had the strongest association with NAFLD compared to SBP and DBP. This finding was confirmed in populations without exercise habits, under 60 years of age, with normal blood pressure, and in non-obese groups. Furthermore, based on ROC analysis, MAP was found to have the highest accuracy in identifying NAFLD compared to the other three blood pressure indices. Conclusion Among the four blood pressure indices evaluated, MAP demonstrates the greatest efficacy in identifying NAFLD and assessing its associated risk. These findings underscore the potential of MAP as the most promising blood pressure index for screening NAFLD.
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Affiliation(s)
- Chong Hu
- Department of Gastroenterology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Ziqi Yu
- Munich Medical Research School, LMU Munich, Munich, Germany
| | - Changli Wei
- Department of Gastroenterology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Guotai Sheng
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Jianyong Chen
- Department of Gastroenterology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
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Li Y, Wu S, Gao J, Zhang Y, Zuo Y, Tian X, Chen S, Xing A, Wang A, He Y. Association of Stroke With Metabolic Dysfunction-Associated Fatty Liver Disease With and Without CKD. Am J Kidney Dis 2024; 83:477-488. [PMID: 37838141 DOI: 10.1053/j.ajkd.2023.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/09/2023] [Accepted: 08/26/2023] [Indexed: 10/16/2023]
Abstract
RATIONALE & OBJECTIVE Metabolic dysfunction-associated fatty liver disease (MAFLD), a risk factor for stroke and all-cause mortality, is highly prevalent among patients with chronic kidney disease (CKD), but it is unclear whether the association of MAFLD with stroke and all-cause mortality differs within and outside of the setting of CKD. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS We enrolled 95,353 participants from the Kailuan Cohort Study, among whom 35,749 had CKD at baseline or developed CKD during the follow-up period, and 59,604 individuals who had no CKD at baseline or during the follow-up period. EXPOSURE MAFLD. OUTCOME Stroke (ischemic stroke, hemorrhagic stroke), all-cause mortality. ANALYTICAL APPROACH Adjusted Cox regression models were used to estimate the influence of MAFLD on stroke outcomes within the subgroups defined by the presence of CKD. RESULTS After a median follow-up of 12.8 years, 6,140 strokes (6.4%) and 11,975 deaths from any cause (12.6%) occurred. After adjusting for potential confounders, MAFLD was associated with an increased incidence of stroke among the participants with CKD (HR, 1.34 [95% CI, 1.23-1.45]) but not among those without CKD (HR, 1.05 [95% CI, 0.97-1.15]; Pinteraction<0.001). This association was principally related to ischemic stroke (HR, 1.38 [95% CI, 1.26-1.51]) and not hemorrhagic stroke (HR, 1.04 [95% CI, 0.85-1.26]). No association was found between MAFLD and all-cause mortality in the participants with CKD (HR,1.04 [95% CI, 0.98-1.10]) or those without CKD (HR,1.03 [95% CI, 0.97-1.09]). Among the participants with CKD, compared with non-MAFLD, MAFLD with diabetes (HR,1.36 [95% CI, 1.23-1.50]) or overweight/obesity (HR,1.30 [95% CI, 1.14-1.50]) was associated with a higher risk of stroke whereas MAFLD without overweight/obesity or diabetes was not associated with a higher risk (HR,1.08 [95% CI, 0.81-1.43]). LIMITATIONS This was an observational study and included individuals with CKD who had a relatively high estimated glomerular filtration rate. CONCLUSIONS MAFLD was associated with an increased risk of stroke in individuals with CKD but not in those without CKD. PLAIN-LANGUAGE SUMMARY Metabolic dysfunction-associated fatty liver disease (MAFLD), which is recognized as a risk factor for stroke in the general population, is highly prevalent among individuals with chronic kidney disease (CKD). However, the impact of MAFLD on the risk of stroke in patients with CKD remains uncertain. We investigated the association of MAFLD with stroke in individuals with and without CKD. Our analysis revealed that MAFLD was associated with a significantly increased risk of stroke in individuals with CKD, and the magnitude of this increased risk was greater in the setting of CKD. These findings highlight the need for increased attention to MAFLD in patients with CKD and emphasize that addressing and preventing MAFLD in this population may contribute to reduced morbidity from stroke.
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Affiliation(s)
- Yuhao Li
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, People's Republic of China; Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, People's Republic of China
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, Tangshan, People's Republic of China
| | - Jingli Gao
- Department of Intensive Care Unit, Kailuan General Hospital, Tangshan, People's Republic of China
| | - Yijun Zhang
- Department of Clinical Epidemiology and Clinical Trial, Capital Medical University, Beijing, People's Republic of China; Department of Neurology, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yingting Zuo
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xue Tian
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, People's Republic of China; Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, People's Republic of China
| | - Shuohua Chen
- Department of Cardiology, Kailuan General Hospital, Tangshan, People's Republic of China
| | - Aijun Xing
- Department of Cardiology, Kailuan General Hospital, Tangshan, People's Republic of China
| | - Anxin Wang
- Department of Clinical Epidemiology and Clinical Trial, Capital Medical University, Beijing, People's Republic of China; Department of Neurology, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.
| | - Yan He
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, People's Republic of China; Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, People's Republic of China.
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McArthur E, Smith G, Sood MM, Blake PG, Brimble KS, Muanda FT, Garg AX, Dixon SN. Impact of the 2021 CKD-EPI eGFR Equation on Kidney Care Referral Criteria in Ontario, Canada: A Population-based Cross-sectional Study. Can J Kidney Health Dis 2024; 11:20543581241229258. [PMID: 38524801 PMCID: PMC10960975 DOI: 10.1177/20543581241229258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/04/2023] [Indexed: 03/26/2024] Open
Abstract
Background In some jurisdictions, individuals become eligible or recommended for referral for different types of kidney care using criteria based on their estimated glomerular filtration rate (eGFR). Historically, GFR was estimated with an equation developed in 2009, which included a Black race term. An updated, race-free equation was developed in 2021. It is unclear how adoption of the 2021 equation will influence the number of individuals meeting referral criteria to receive different types of kidney care. Objective To develop population-based estimates on how the number of individuals meeting the eGFR-based referral criteria to receive three different types of kidney care (nephrologist consultation, care in a multi-care specialty clinic, kidney transplant evaluation) changes when the 2021 versus 2009 equation is used to calculate eGFR. Design Population-based, cross-sectional study. Setting Ontario, Canada's most populous province with 14.2 million residents as of 2021. Less than 5% of Ontario's residents self-identify as being of Black race. Patients Adults with at least one outpatient serum creatinine measurement in the 2 years prior to December 31, 2021. Measurements Referral criteria to 3 different types of kidney care: nephrologist consultation, multi-care specialty clinic, and evaluation for a kidney transplant. The eGFR thresholds used to define referral eligibility or recommendation for these kidney health services were based on guidelines from Ontario's provincial renal agency. Methods The number of individuals meeting referral criteria for the 3 different healthcare services was compared between the 2009 and 2021 equations, restricted to individuals not yet receiving that level of care. As individual-level race data were not available, estimates were repeated, randomly assigning a Black race status to 1%, 5%, and 10% of the population. Results We had an outpatient serum creatinine measurement available for 1 048 110 adults. Using the 2009 equation, 37 345 individuals met the criteria to be referred to a nephrologist, 10 019 met the criteria to receive care in a multi-care specialty clinic, and 10 178 met the criteria to be referred for kidney transplant evaluation. Corresponding numbers with the 2021 equation (and the percent relative to the 2009 equation) were 26 645 (71.3%), 9009 (89.9%), and 8615 (84.6%) individuals, respectively. These numbers were largely unchanged when Black race was assumed in up to 10% of the population. Limitations Referral criteria based solely on urine albumin-to-creatinine ratio were not assessed. Self-reported race data were unavailable. Conclusions For healthcare planning, in regions where a minority of the population is Black, a substantial number of individuals may no longer meet referral criteria for different types of kidney healthcare following adoption of the new 2021 eGFR equation.
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Affiliation(s)
- Eric McArthur
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- ICES, Toronto, ON, Canada
| | - Graham Smith
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- ICES, Toronto, ON, Canada
| | - Manish M. Sood
- ICES, Toronto, ON, Canada
- Department of Medicine, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Ontario Renal Network, Ontario Health, Toronto, Canada
| | - K. Scott Brimble
- Ontario Renal Network, Ontario Health, Toronto, Canada
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Flory T. Muanda
- ICES, Toronto, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Amit X. Garg
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- ICES, Toronto, ON, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Stephanie N. Dixon
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- ICES, Toronto, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Zafari Z, Park JE, Shah CH, dosReis S, Gorman EF, Hua W, Ma Y, Tian F. The State of Use and Utility of Negative Controls in Pharmacoepidemiologic Studies. Am J Epidemiol 2024; 193:426-453. [PMID: 37851862 DOI: 10.1093/aje/kwad201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/27/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
Uses of real-world data in drug safety and effectiveness studies are often challenged by various sources of bias. We undertook a systematic search of the published literature through September 2020 to evaluate the state of use and utility of negative controls to address bias in pharmacoepidemiologic studies. Two reviewers independently evaluated study eligibility and abstracted data. Our search identified 184 eligible studies for inclusion. Cohort studies (115, 63%) and administrative data (114, 62%) were, respectively, the most common study design and data type used. Most studies used negative control outcomes (91, 50%), and for most studies the target source of bias was unmeasured confounding (93, 51%). We identified 4 utility domains of negative controls: 1) bias detection (149, 81%), 2) bias correction (16, 9%), 3) P-value calibration (8, 4%), and 4) performance assessment of different methods used in drug safety studies (31, 17%). The most popular methodologies used were the 95% confidence interval and P-value calibration. In addition, we identified 2 reference sets with structured steps to check the causality assumption of the negative control. While negative controls are powerful tools in bias detection, we found many studies lacked checking the underlying assumptions. This article is part of a Special Collection on Pharmacoepidemiology.
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Abdullah SS, Rostamzadeh N, Muanda FT, McArthur E, Weir MA, Sontrop JM, Kim RB, Kamran S, Garg AX. High-Throughput Computing to Automate Population-Based Studies to Detect the 30-Day Risk of Adverse Outcomes After New Outpatient Medication Use in Older Adults with Chronic Kidney Disease: A Clinical Research Protocol. Can J Kidney Health Dis 2024; 11:20543581231221891. [PMID: 38186562 PMCID: PMC10771740 DOI: 10.1177/20543581231221891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Safety issues are detected in about one third of prescription drugs in the years following regulatory agency approval. Older adults, especially those with chronic kidney disease, are at particular risk of adverse reactions to prescription drugs. This protocol describes a new approach that may identify credible drug-safety signals more efficiently using administrative health care data. Objective To use high-throughput computing and automation to conduct 700+ drug-safety cohort studies in older adults in Ontario, Canada. Each study will compare 74 acute (30-day) outcomes in patients who start a new prescription drug (new users) to a group of nonusers with similar baseline health characteristics. Risks will be assessed within strata of baseline kidney function. Design and setting The studies will be population-based, new-user cohort studies conducted using linked administrative health care databases in Ontario, Canada (January 1, 2008, to March 1, 2020). The source population for these studies will be residents of Ontario aged 66 years or older who filled at least one outpatient prescription through the Ontario Drug Benefit (ODB) program during the study period (all residents have universal health care, and those aged 65+ have universal prescription drug coverage through the ODB). Patients We identified 3.2 million older adults in the source population during the study period and built 700+ initial medication cohorts, each containing mutually exclusive groups of new users and nonusers. Nonusers were randomly assigned cohort entry dates that followed the same distribution of prescription start dates as new users. Eligibility criteria included a baseline estimated glomerular filtration rate (eGFR) measurement within 12 months before the cohort entry date (median time was 71 days before cohort entry in the new user group), no prior receipt of maintenance dialysis or a kidney transplant, and no prior prescriptions for drugs in the same subclass as the study drug. New users and nonusers will be balanced on ~400 baseline health characteristics using inverse probability of treatment weighting on propensity scores within 3 strata of baseline eGFR: ≥60, 45 to <60, <45 mL/min per 1.73 m2. Outcomes We will compare new user and nonuser groups on 74 clinically relevant outcomes (17 composites and 57 individual outcomes) in the 30 days after cohort entry. We used a prespecified approach to identify these 74 outcomes. Statistical analysis plan In each cohort, we will obtain eGFR-stratum-specific weighted risk ratios and risk differences using modified Poisson regression and binomial regression, respectively. Additive and multiplicative interaction by eGFR category will be examined. Drug-outcome associations that meet prespecified criteria (identified signals) will be further examined in additional analyses (including survival, negative-control exposure, and E-value analyses) and visualizations. Results The initial medication cohorts had a median of 6120 new users per cohort (interquartile range: 1469-38 839) and a median of 1 088 301 nonusers (interquartile range: 751 697-1 267 009). Medications with the largest number of new users were amoxicillin trihydrate (n = 1 000 032), cephalexin (n = 571 566), prescription acetaminophen (n = 571 563), and ciprofloxacin (n = 504,374); 19% to 29% of new users in these cohorts had an eGFR <60 mL/min per 1.73 m2. Limitations Despite our use of robust techniques to balance baseline indicators and to control for confounding by indication, residual confounding will remain a possibility. Only acute (30-day) outcomes will be examined. Our data sources do not include nonprescription (over-the-counter) drugs or drugs prescribed in hospitals and do not include outpatient prescription drug use in children or adults <65 years. Conclusion This accelerated approach to conducting postmarket drug-safety studies has the potential to more efficiently detect drug-safety signals in a vulnerable population. The results of this protocol may ultimately help improve medication safety.
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Affiliation(s)
| | - Neda Rostamzadeh
- Insight Lab, Western University and ICES Western, London, ON, Canada
| | - Flory T. Muanda
- London Health Sciences Centre, Western University and ICES Western, London, ON, Canada
| | - Eric McArthur
- London Health Sciences Centre and ICES Western, London, ON, Canada
| | - Matthew A. Weir
- London Health Sciences Centre, Western University and ICES Western, London, ON, Canada
| | | | | | - Sedig Kamran
- Insight Lab, Western University, London, ON, Canada
| | - Amit X. Garg
- London Health Sciences Centre, Western University and ICES Western, London, ON, Canada
- Victoria Hospital, London Health Sciences Centre, London, ON, Canada
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12
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Hwang YJ, Chang AR, Brotman DJ, Inker LA, Grams ME, Shin JI. Baclofen and the risk of fall and fracture in older adults: A real-world cohort study. J Am Geriatr Soc 2024; 72:91-101. [PMID: 37933734 PMCID: PMC10872960 DOI: 10.1111/jgs.18665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/31/2023] [Accepted: 08/26/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The growth of oral muscle relaxant prescriptions among older adults in the United States is concerning due to the drugs' adverse sedative effects. Baclofen is a gamma-aminobutyric acid agonist muscle relaxant that is associated with encephalopathy. We characterized the risk of fall and fracture associated with oral baclofen against other muscle relaxants (tizanidine or cyclobenzaprine) in older adults. METHODS We designed a new-user, active-comparator study using tertiary health system data from Geisinger Health, Pennsylvania (January 2005 through December 2018). Older adults (aged ≥65 years) newly treated with baclofen, tizanidine, or cyclobenzaprine were included. Propensity score-based inverse probability of treatment weighting (IPTW) was used to balance the treatment groups on 58 baseline characteristics. Fine-Gray competing risk regression was used to estimate the risk of fall and fracture. RESULTS The study cohort comprised of 2205 new baclofen users, 1103 new tizanidine users, and 9708 new cyclobenzaprine users. During a median follow-up of 100 days, baclofen was associated with a higher risk of fall compared to tizanidine (IPTW incidence rate, 108.4 vs. 61.9 per 1000 person-years; subdistribution hazard ratio [SHR], 1.68 [95% CI, 1.20-2.36]). The risk of fall associated with baclofen was comparable to cyclobenzaprine (SHR, 1.17 [95% CI, 0.93-1.47]) with a median follow-up of 106 days. The risk of fracture was similar among patients treated with baclofen versus tizanidine (SHR, 0.85 [95% CI, 0.63-1.14]) or cyclobenzaprine (SHR, 0.85 [95% CI, 0.67-1.07]). CONCLUSIONS The risk of fall associated with baclofen was greater than tizanidine, but not compared to cyclobenzaprine in older adults. The risk of fracture was comparable among the older users of baclofen, tizanidine, and cyclobenzaprine. Our findings may inform risk-benefit considerations in the increasingly common clinical encounters where oral muscle relaxants are prescribed.
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Affiliation(s)
- Y. Joseph Hwang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD
| | - Alex R. Chang
- Kidney Health Research Institute, Geisinger Health, Danville, PA
| | - Daniel J. Brotman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Departments of Medicine and Population Health, NYU Grossman School of Medicine, New York City, NY
| | - Jung-Im Shin
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
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13
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Qiu J, Kuang M, He S, Yu C, Wang C, Huang X, Sheng G, Zou Y. Gender perspective on the association between liver enzyme markers and non-alcoholic fatty liver disease: insights from the general population. Front Endocrinol (Lausanne) 2023; 14:1302322. [PMID: 38125795 PMCID: PMC10731038 DOI: 10.3389/fendo.2023.1302322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
Objective Every distinct liver enzyme biomarker exhibits a strong correlation with non-alcoholic fatty liver disease (NAFLD). This study aims to comprehensively analyze and compare the associations of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) with NAFLD from a gender perspective. Methods This study was conducted on 6,840 females and 7,411 males from the NAGALA cohort. Multivariable logistic regression analysis was used to compare the associations between liver enzyme markers and NAFLD in both genders, recording the corresponding adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Receiver operating characteristic (ROC) curves were used to evaluate the accuracy of individual liver enzyme markers and different combinations of them in identifying NAFLD. Results Liver enzyme markers ALT, AST, and GGT were all independently associated with NAFLD and exhibited significant gender differences (All P-interaction<0.05). In both genders, ALT exhibited the most significant association with NAFLD, with adjusted standardized ORs of 2.19 (95% CI: 2.01-2.39) in males and 1.60 (95% CI: 1.35-1.89) in females. Additionally, ROC analysis showed that ALT had significantly higher accuracy in identifying NAFLD than AST and GGT in both genders (Delong P-value < 0.05), and the accuracy of ALT in identifying NAFLD in males was higher than that in females [Area under the ROC curve (AUC): male 0.79, female 0.77]. Furthermore, out of the various combinations of liver enzymes, ALT+GGT showed the highest accuracy in identifying NAFLD in both genders, with AUCs of 0.77 (95% CI: 0.75-0.79) in females and 0.79 (95% CI: 0.78-0.81) in males. Conclusion Our study revealed significant gender differences in the associations of the three commonly used liver enzyme markers with NAFLD. In both genders, the use of ALT alone may be the simplest and most effective tool for screening NAFLD, especially in males.
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Affiliation(s)
- Jiajun Qiu
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Maobin Kuang
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Shiming He
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Changhui Yu
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Chao Wang
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Xin Huang
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Guotai Sheng
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
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14
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Qiu J, Kuang M, Zou Y, Yang R, Shangguan Q, Liu D, Sheng G, Wang W. The predictive significance of lipid accumulation products for future diabetes in a non-diabetic population from a gender perspective: an analysis using time-dependent receiver operating characteristics. Front Endocrinol (Lausanne) 2023; 14:1285637. [PMID: 38034005 PMCID: PMC10682705 DOI: 10.3389/fendo.2023.1285637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Objective The increasing prevalence of diabetes is strongly associated with visceral adipose tissue (VAT), and gender differences in VAT remarkably affect the risk of developing diabetes. This study aimed to assess the predictive significance of lipid accumulation products (LAP) for the future onset of diabetes from a gender perspective. Methods A total of 8,430 male and 7,034 female non-diabetic participants in the NAGALA (NAfld in the Gifu Area, Longitudinal Analysis) program were included. The ability of LAP to assess the risk of future new-onset diabetes in both genders was analyzed using multivariate Cox regression. Subgroup analysis was conducted to explore the impact of potential modifiers on the association between LAP and diabetes. Additionally, time-dependent receiver operator characteristics (ROC) curves were used to assess the predictive power of LAP in both genders for new-onset diabetes over the next 2-12 years. Results Over an average follow-up of 6.13 years (maximum 13.14 years), 373 participants developed diabetes. Multivariate Cox regression analysis showed a significant gender difference in the association between LAP and future diabetes risk (P-interaction<0.05): the risk of diabetes associated with LAP was greater in females than males [hazard ratios (HRs) per standard deviation (SD) increase: male 1.20 (1.10, 1.30) vs female 1.35 (1.11, 1.64)]. Subgroup analysis revealed no significant modifying effect of factors such as age, body mass index (BMI), smoking history, drinking history, exercise habits, and fatty liver on the risk of diabetes associated with LAP (All P-interaction <0.05). Time-dependent ROC analysis showed that LAP had greater accuracy in predicting diabetes events occurring within the next 2-12 years in females than males with more consistent predictive thresholds in females. Conclusions This study highlighted a significant gender difference in the association between LAP and future diabetes risk. The risk of diabetes associated with LAP was greater in females than in males. Furthermore, LAP showed superior predictive ability for diabetes at different time points in the future in females and had more consistent and stable predictive thresholds in females, particularly in the medium and long term.
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Affiliation(s)
- Jiajun Qiu
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Maobin Kuang
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Ruijuan Yang
- Department of Internal Medicine, Medical College of Nanchang University, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Department of Endocrinology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Qing Shangguan
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Dingyang Liu
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Guotai Sheng
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Wei Wang
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
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Muanda FT, Blake PG, Weir MA, Ahmadi F, McArthur E, Sontrop JM, Urquhart BL, Kim RB, Garg AX. Low-Dose Methotrexate and Serious Adverse Events Among Older Adults With Chronic Kidney Disease. JAMA Netw Open 2023; 6:e2345132. [PMID: 38010652 PMCID: PMC10682837 DOI: 10.1001/jamanetworkopen.2023.45132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/17/2023] [Indexed: 11/29/2023] Open
Abstract
Importance Low-dose methotrexate is used to treat rheumatoid arthritis and psoriasis. Due to its kidney elimination, better evidence is needed to inform its safety in adults with chronic kidney disease (CKD). Objectives To compare the 90-day risk of serious adverse events among adults with CKD who started low-dose methotrexate vs those who started hydroxychloroquine and to compare the risk of serious adverse events among adults with CKD starting 2 distinct doses of methotrexate vs those starting hydroxychloroquine. Design, Setting, and Participants This retrospective, population-based, new-user cohort study was conducted in Ontario, Canada (2008-2021) using linked administrative health care data. Adults aged 66 years or older with CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2 but not receiving dialysis) who started low-dose methotrexate (n = 2309) were matched 1:1 with those who started hydroxychloroquine. Exposure Low-dose methotrexate (5-35 mg/wk) vs hydroxychloroquine (200-400 mg/d). Main Outcome and Measure The primary outcome was a composite of serious adverse events: a hospital visit with myelosuppression, sepsis, pneumotoxic effects, or hepatotoxic effects within 90 days of starting the study drug. Prespecified subgroup analyses were conducted by eGFR category. Propensity score matching was used to balance comparison groups on indicators of baseline health. Risk ratios (RRs) were obtained using modified Poisson regression, and risk differences (RDs) using binomial regression. Results In a propensity score-matched cohort of 4618 adults with CKD (3192 [69%] women; median [IQR] age, 76 [71-82] years), the primary outcome was higher in patients who started low-dose methotrexate vs those who started hydroxychloroquine (82 of 2309 [3.55%] vs 40 of 2309 [1.73%]; RR, 2.05 (95% CI, 1.42-2.96); RD, 1.82% [95% CI, 0.91%-2.73%]). In subgroup analysis, the risks increased progressively at lower eGFR (eg, eGFR <45 mL/min/1.73 m2: RR, 2.79 [95% CI, 1.51-5.13]). In the secondary comparison with hydroxychloroquine, methotrexate users at 15 to 35 mg/wk had a higher risk of the primary outcome. Conclusions and Relevance In this cohort of 4618 older patients with CKD, the 90-day risk of serious adverse events was higher among those who started low-dose methotrexate than those who started hydroxychloroquine. If verified, these risks should be balanced against the benefits of low-dose methotrexate use.
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Affiliation(s)
- Flory T. Muanda
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Matthew A. Weir
- ICES Western, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Fatemeh Ahmadi
- ICES Western, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Eric McArthur
- ICES Western, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Jessica M. Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Brad L. Urquhart
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Richard B. Kim
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
| | - Amit X. Garg
- ICES Western, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
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Vidanapathirana MN, Palliyaguruge T, Wijewickrama E. Baclofen-induced myoclonus in patients with renal impairment: A case series. SAGE Open Med Case Rep 2023; 11:2050313X231200966. [PMID: 37719637 PMCID: PMC10503278 DOI: 10.1177/2050313x231200966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/18/2023] [Indexed: 09/19/2023] Open
Abstract
Baclofen is a derivative of gamma amino butyric acid and is used for control of pain and muscular spasms. It is primarily excreted via the kidneys. In patients with impaired renal functions, the half-life of baclofen is prolonged and symptoms of toxicity can occur with normal doses. Commonly reported symptoms of baclofen toxicity are somnolence, altered mentation, seizures and respiratory depression. Myoclonus secondary to baclofen toxicity is scarcely reported. This case series describes two patients with chronic kidney disease (CKD) who were prescribed regular doses of baclofen for analgesia, and subsequently developed generalized myoclonus. The symptoms resolved with omission of baclofen and haemodialysis. There is currently no consensus on dose modification of baclofen in renal impairment for prevention of adverse neurological events. However, considering the surmounting evidence for low threshold of baclofen toxicity in CKD, dose adjustment protocols or consensus on contraindication need to be established.
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Yau K, McArthur E, Jeyakumar N, Tsobo Muanda F, Kim RB, Clemens KK, Wald R, Garg AX. Adverse events with quetiapine and clarithromycin coprescription: A population-based retrospective cohort study. Health Sci Rep 2023; 6:e1375. [PMID: 37359413 PMCID: PMC10290079 DOI: 10.1002/hsr2.1375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
Background and Aims Quetiapine is an atypical antipsychotic predominantly metabolized by the cytochrome P450 3A4 (CYP3A4) enzyme. We studied the risk of adverse events following coprescription of clarithromycin (a strong CYP3A4 inhibitor) versus azithromycin (not a CYP3A4 inhibitor) in quetiapine users. Materials and Methods This was a population-based retrospective cohort study from 2004 to 2020 in Ontario, Canada in adult quetiapine users newly co-prescribed clarithromycin (n = 16,909) or azithromycin (n = 25,267). The primary outcome was the composite of hospital encounters with encephalopathy (defined as a diagnosis of delirium, disorientation, transient alteration of awareness, transient ischemic attack, or unspecified dementia), a fall, or a fracture within 30 days of new coprescription. Secondary outcomes were individual components of the composite outcome, hospital encounter with computed tomography (CT) head scan, and all-cause mortality. Results Coprescription of clarithromycin versus azithromycin with quetiapine was associated with a higher risk of the primary composite outcome (365 of 16,909 clarithromycin users [2.2%] vs. 309 of 16,929 azithromycin users [1.8%]; absolute risk increase, 0.34% [95% confidence interval, CI, 0.04-0.63]; relative risk [RR], 1.19 [95% CI, 1.02-1.38]). This was primarily driven by an increase in fragility fractures (78 of 16,909 clarithromycin users [0.5%] vs. 45 of 16,923 azithromycin users [0.3%]; absolute risk increase, 0.20% [95% CI, 0.07-0.32]; RR, 1.74 [95% CI, 1.21-2.52]). Hospital encounters with a CT head scan were higher in clarithromycin users (220 of 16,909 [1.3%] vs. 175 of 16,923 azithromycin users [1.0%]; absolute risk increase, 0.27% [95% CI, 0.04-0.50]; RR, 1.26 [95% CI, 1.04-1.54]), but there was no difference in hospital encounters with encephalopathy, falls, or all-cause mortality between macrolide groups. Conclusion Among adults taking quetiapine, concurrent use of clarithromycin compared with azithromycin was associated with a small but statistically greater 30-day risk of a hospital encounter for encephalopathy, falls, or fracture, which was predominantly related to a higher rate of fragility fractures.
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Affiliation(s)
- Kevin Yau
- Division of NephrologyTemerty Faculty of MedicineTorontoOntarioCanada
| | - Eric McArthur
- Institute for Clinical Evaluative SciencesOntarioCanada
- London Health Sciences CentreLawson Health Research InstituteLondonOntarioCanada
| | - Nivethika Jeyakumar
- Institute for Clinical Evaluative SciencesOntarioCanada
- London Health Sciences CentreLawson Health Research InstituteLondonOntarioCanada
| | - Flory Tsobo Muanda
- Institute for Clinical Evaluative SciencesOntarioCanada
- Department of Physiology & PharmacologyWestern UniversityLondonOntarioCanada
| | - Richard B. Kim
- London Health Sciences CentreLawson Health Research InstituteLondonOntarioCanada
- Division of Clinical Pharmacology, Department of MedicineWestern UniversityLondonOntarioCanada
| | - Kristin K. Clemens
- Institute for Clinical Evaluative SciencesOntarioCanada
- London Health Sciences CentreLawson Health Research InstituteLondonOntarioCanada
- Division of Endocrinology, Department of MedicineWestern UniversityLondonOntarioCanada
- Department of Epidemiology & BiostatisticsWestern UniversityLondonOntarioCanada
| | - Ron Wald
- Division of NephrologyTemerty Faculty of MedicineTorontoOntarioCanada
- Institute for Clinical Evaluative SciencesOntarioCanada
- Li Ka Shing Knowledge InstituteSt. Michael's HospitalTorontoOntarioCanada
| | - Amit X. Garg
- Institute for Clinical Evaluative SciencesOntarioCanada
- London Health Sciences CentreLawson Health Research InstituteLondonOntarioCanada
- Department of Epidemiology & BiostatisticsWestern UniversityLondonOntarioCanada
- Division of Nephrology, Department of MedicineWestern UniversityLondonOntarioCanada
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18
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Kuang M, Yang R, Huang X, Wang C, Sheng G, Xie G, Zou Y. Assessing temporal differences in the predictive power of baseline TyG-related parameters for future diabetes: an analysis using time-dependent receiver operating characteristics. J Transl Med 2023; 21:299. [PMID: 37138277 PMCID: PMC10158224 DOI: 10.1186/s12967-023-04159-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/25/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND It is known that measuring the triglyceride glucose (TyG) index and TyG-related parameters [triglyceride glucose-body mass index (TyG-BMI), triglyceride glucose-waist circumference (TyG-WC), and triglyceride glucose-waist to height ratio (TyG-WHtR)] can predict diabetes; this study aimed to compare the predictive value of the baseline TyG index and TyG-related parameters for the onset of diabetes at different future periods. METHODS We conducted a longitudinal cohort study involving 15,464 Japanese people who had undergone health physical examinations. The subject's TyG index and TyG-related parameters were measured at the first physical examination, and diabetes was defined according to the American Diabetes Association criteria. Multivariate Cox regression models and time-dependent receiver operating characteristic (ROC) curves were constructed to examine and compare the risk assessment/predictive value of the TyG index and TyG-related parameters for the onset of diabetes in different future periods. RESULTS The mean follow-up period of the current study cohort was 6.13 years, with a maximum of 13 years, and the incidence density of diabetes was 39.88/10,000 person-years. In multivariate Cox regression models with standardized hazard ratios (HRs), we found that both the TyG index and TyG-related parameters were significantly and positively associated with diabetes risk and that the TyG-related parameters were stronger in assessing diabetes risk than the TyG index, with TyG-WC being the best parameter (HR per SD increase: 1.70, 95% CI 1.46, 1.97). In addition, TyG-WC also showed the highest predictive accuracy in time-dependent ROC analysis for diabetes occurring in the short-term (2-6 years), while TyG-WHtR had the highest predictive accuracy and the most stable predictive threshold for predicting the onset of diabetes in the medium- to long-term (6-12 years). CONCLUSIONS These results suggest that the TyG index combined with BMI, WC, and WHtR can further improve its ability to assess/predict the risk of diabetes in different future periods, where TyG-WC was not only the best parameter for assessing diabetes risk but also the best risk marker for predicting future diabetes in the short-term, while TyG-WHtR may be more suitable for predicting future diabetes in the medium- to long-term.
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Affiliation(s)
- Maobin Kuang
- Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Ruijuan Yang
- Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China
- Department of Endocrinology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Xin Huang
- Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Chao Wang
- Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Guotai Sheng
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Guobo Xie
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China.
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China.
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19
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Hwang YJ, Chang AR, Brotman DJ, Inker LA, Grams ME, Shin JI. Baclofen and the Risk of Encephalopathy: A Real-World, Active-Comparator Cohort Study. Mayo Clin Proc 2023; 98:676-688. [PMID: 37028980 PMCID: PMC10159882 DOI: 10.1016/j.mayocp.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/10/2022] [Accepted: 11/03/2022] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To quantify the risk of encephalopathy associated with oral baclofen compared with other muscle relaxants-tizanidine or cyclobenzaprine. PATIENTS AND METHODS We conducted a new-user, active-comparator study of 2 pairwise cohorts using tertiary health system data from Geisinger Health in Pennsylvania (January 1, 2005, through December 31, 2018). Adults (aged ≥18 years) newly treated with baclofen or tizanidine were included in cohort 1. Adults newly treated with baclofen or cyclobenzaprine were included in cohort 2. Propensity score-based inverse probability of treatment weighting (IPTW) was used to balance the respective cohorts on 45 patient characteristics. Fine-Gray competing risk regression was used to estimate the risk of encephalopathy. RESULTS Cohort 1 included 16,192 new baclofen users and 9782 new tizanidine users. The 30-day risk of encephalopathy was higher in patients treated with baclofen vs tizanidine (IPTW incidence rate, 64.7 vs 28.3 per 1000 person-years) with an IPTW subdistribution hazard ratio (SHR) of 2.29 (95% CI, 1.43 to 3.67). This risk persisted through 1 year (SHR, 1.32 [95% CI, 1.07 to 1.64]). Similarly in cohort 2, baclofen vs cyclobenzaprine was associated with a greater risk of encephalopathy at 30 days (SHR, 2.35 [95% CI, 1.59 to 3.48]) that persisted through the first year of treatment (SHR, 1.94 [95% CI, 1.56 to 2.40]). CONCLUSION The risk of encephalopathy was greater with baclofen vs tizanidine or cyclobenzaprine use. The elevated risk was apparent as early as 30 days and persisted through the first year of treatment. Our findings from routine care settings may inform shared treatment decisions between patients and prescribers.
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Affiliation(s)
- Y Joseph Hwang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD.
| | - Alex R Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Kidney Health Research Institute, Geisinger Health, Danville, PA
| | - Daniel J Brotman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Morgan E Grams
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD; Departments of Medicine and Population Health, NYU Grossman School of Medicine, New York City, NY
| | - Jung-Im Shin
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
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20
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Muanda FT, Sontrop JM, Garg AX. Reviewing the Evidence of the Association Between Baclofen and Encephalopathy. Mayo Clin Proc 2023; 98:647-649. [PMID: 37137637 DOI: 10.1016/j.mayocp.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Flory T Muanda
- ICES, Ontario, Canada, Department of Physiology and Pharmacology, Western University, London, Ontario, Canada, Department of Epidemiology & Biostatistics, Western University, London, Canada.
| | - Jessica M Sontrop
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Amit X Garg
- ICES, Ontario, Canada, Department of Epidemiology & Biostatistics, Western University, London, Canada, Division of Nephrology, Department of Medicine, Western University, London, Canada
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21
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Su Zhang VR, Niu F, Lee EA, DiStasio C, Broder BI, Steinberg SG, Hui RL. Safety of baclofen versus tizanidine for older adults with musculoskeletal pain. J Am Geriatr Soc 2023. [PMID: 36989193 DOI: 10.1111/jgs.18349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/15/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Baclofen and tizanidine are both muscle relaxants that carry the risk for neuropsychiatric events in older adults but there is a lack of data directly comparing their safety. This study aimed to investigate the relative risk between these two medications in causing injury and delirium in older adults. METHODS This was a retrospective cohort study that was completed in an integrated healthcare system in the United States and included patients aged 65 years or older who started baclofen or tizanidine for the treatment of musculoskeletal pain from January 2016 through December 2018. Outcomes included new incidence of injury (concussion, contusion, dislocation, fall, fracture, or other injuries) and delirium. The cohort was followed from the initiation of therapy until the first occurrence of any of the following events: end of the index drug exposure, end of health plan membership, death, or the study end date of December 31st, 2019. Descriptive statistics were used to compare baseline patient characteristics between baclofen and tizanidine treatment groups. Cox proportional hazards model was used to calculate adjusted hazard ratios (HRs) with 95% confidence intervals. RESULTS The final study cohort included 12,101 and 6,027 older adults in the baclofen and tizanidine group respectively (mean age 72.2 ± 6.2 years old, 59% female). Older adults newly started on baclofen had a greater risk of injury (HR = 1.54, 95% CI = 1.21-1.96, P = < 0.001) and delirium (HR = 3.33, 95% CI = 2.11-5.26, p = <0.001) compared to those started on tizanidine. CONCLUSION The results of this study suggest that baclofen is associated with higher incidences of injury and delirium compared to tizanidine when used for the treatment of musculoskeletal pain. Future studies should investigate if these risks are dose-related and include a comparison group not exposed to either drug.
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Affiliation(s)
- Vanessa R Su Zhang
- Department of Ambulatory Care Pharmacy, Kaiser Permanente, San Rafael, California, USA
| | - Fang Niu
- Pharmacy Outcomes Research Group, Kaiser Permanente, Downey, California, USA
| | - Eric A Lee
- Department of Internal Medicine, Southern California Permanente Medical Group, West Los Angeles, California, USA
| | - Christopher DiStasio
- Department of Neurology, Southern California Permanente Medical Group, Harbor City, California, USA
| | - Benjamin I Broder
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California, USA
| | - Steven G Steinberg
- Department of Family Medicine, Southern California Permanente Medical Group, Panorama City, California, USA
| | - Rita L Hui
- Pharmacy Outcomes Research Group, Kaiser Permanente, Oakland, California, USA
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22
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Lu S, Xie Q, Kuang M, Hu C, Li X, Yang H, Sheng G, Xie G, Zou Y. Lipid metabolism, BMI and the risk of nonalcoholic fatty liver disease in the general population: evidence from a mediation analysis. J Transl Med 2023; 21:192. [PMID: 36915168 PMCID: PMC10012451 DOI: 10.1186/s12967-023-04047-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Body mass index (BMI) and lipid parameters are the most commonly used anthropometric parameters and biomarkers for assessing nonalcoholic fatty liver disease (NAFLD) risk. This study aimed to assess and quantify the mediating role of traditional and non-traditional lipid parameters on the association between BMI and NAFLD. METHOD Using data from 14,251 subjects from the NAGALA (NAfld in the Gifu Area, Longitudinal Analysis) study, mediation analyses were performed to explore the roles of traditional [total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C)] and non-traditional [non-HDL-C, remnant cholesterol (RC), TC/HDL-C ratio, LDL-C/HDL-C ratio, TG/HDL-C ratio, non-HDL-C/HDL-C ratio, and RC/HDL-C ratio] lipid parameters in the association of BMI with NAFLD and quantify the mediation effect of these lipid parameters on the association of BMI with NAFLD using the percentage of mediation. RESULT After fully adjusting for confounders, multivariate regression analysis showed that both BMI and lipid parameters were associated with NAFLD (All P-value < 0.001). Mediation analysis showed that both traditional and non-traditional lipid parameters mediated the association between BMI and NAFLD (All P-value of proportion mediate < 0.001), among which non-traditional lipid parameters such as RC, RC/HDL-C ratio, non-HDL-C/HDL-C ratio, and TC/HDL-C ratio accounted for a relatively large proportion, 11.4%, 10.8%, 10.2%, and 10.2%, respectively. Further stratified analysis according to sex, age, and BMI showed that this mediation effect only existed in normal-weight (18.5 kg/m2 ≤ BMI < 25 kg/m2) people and young and middle-aged (30-59 years old) people; moreover, the mediation effects of all lipid parameters except TC accounted for a higher proportion in women than in men. CONCLUSION The new findings of this study showed that all lipid parameters were involved in and mediated the risk of BMI-related NAFLD, and the contribution of non-traditional lipid parameters to the mediation effect of this association was higher than that of traditional lipid parameters, especially RC, RC/HDL-C ratio, non-HDL-C/HDL-C ratio, and TC/HDL-C ratio. Based on these results, we suggest that we should focus on monitoring non-traditional lipid parameters, especially RC and RC/HDL-C ratio, when BMI intervention is needed in the process of preventing or treating NAFLD.
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Affiliation(s)
- Song Lu
- Department of Cardiology, Jiangxi Provincial People's Hospital, Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China.,Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Qiyang Xie
- Department of Cardiology, Jiangxi Provincial People's Hospital, Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China.,Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Maobin Kuang
- Department of Cardiology, Jiangxi Provincial People's Hospital, Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China.,Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Chong Hu
- Department of Gastroenterology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Xinghui Li
- Fuzhou Dongxiang District People's Hospital, Fuzhou, 331800, Jiangxi, China
| | - Huijian Yang
- Fuzhou Dongxiang District People's Hospital, Fuzhou, 331800, Jiangxi, China
| | - Guotai Sheng
- Department of Cardiology, Jiangxi Provincial People's Hospital, Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China.,Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China
| | - Guobo Xie
- Department of Cardiology, Jiangxi Provincial People's Hospital, Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China. .,Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China.
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, 330006, Jiangxi, China.
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23
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Sheng G, Qiu J, Kuang M, Peng N, Xie G, Chen Y, Zhang S, Zou Y. Assessing temporal differences of baseline body mass index, waist circumference, and waist-height ratio in predicting future diabetes. Front Endocrinol (Lausanne) 2023; 13:1020253. [PMID: 36686484 PMCID: PMC9852880 DOI: 10.3389/fendo.2022.1020253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/15/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Obesity is the prominent modifiable risk factor known to influence the occurrence and progression of diabetes other than age, and the objective of this study was to evaluate and compare the predictive value of three simple baseline anthropometric indicators of obesity, body mass index (BMI), waist circumference (WC), and waist-height ratio (WHtR), for the occurrence of diabetes at different time points in the future. Methods The study subjects were 12,823 individuals with normoglycemic at baseline who underwent health screening and had measurements of BMI, WC, and WHtR. The outcome of interest was new-onset diabetes during follow-up. Time-dependent receiver operator characteristics (ROC) curves of baseline BMI, WC, and WHtR for predicting the risk of diabetes in the next 2 to 12 years were constructed and their area under the ROC curves (AUCs) and corresponding optimal threshold values were calculated for each time point, which were used to compare the accuracy and stability of the above three indicators for predicting the occurrence of diabetes in different future periods. Results During a median follow-up period of 7.02 years, with a maximum follow-up of 13 years, 320 new-onset diabetes were recorded. After adjusting for confounders and comparing standardized hazard ratios (HRs), WC was shown to be the best simple anthropometric indicator of obesity reflecting diabetes risk in all models, followed by WHtR. Time-dependent ROC analysis showed that WC had the highest AUC in predicting the occurrence of diabetes in the short term (2-5 years), and WHtR had the highest AUC in predicting the occurrence of diabetes in the medium to long term (6-12 years), while in any time point, both WC and WHtR had higher AUC than BMI in predicting future diabetes. In addition, we found relatively larger fluctuations in the thresholds of BMI and WC for predicting diabetes over time, while the thresholds of WHtR consistently remained between 0.47-0.50; comparatively speaking, WHtR may have greater application value in predicting future diabetes. Conclusions Our analysis sustained that central obesity is a more important predictor of diabetes, and in clinical practice, we proposed measuring WHtR as a useful tool for predicting future diabetes.
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Affiliation(s)
- Guotai Sheng
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Jiajun Qiu
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, Medical College of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Maobin Kuang
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, Medical College of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Nan Peng
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, Medical College of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Guobo Xie
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Yuanqin Chen
- Jiangxi Provincial Geriatric Hospital, Jiangxi Provincial People’s Hospital, Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Shuhua Zhang
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Yang Zou
- Jiangxi Cardiovascular Research Institute, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
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24
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Muanda FT, Sood MM, Weir MA, Sontrop JM, Ahmadi F, Yoo E, Kim RB, Silverman MS, Knoll GA, Garg AX. Association of Higher-Dose Fluoroquinolone Therapy With Serious Adverse Events in Older Adults With Advanced Chronic Kidney Disease. JAMA Netw Open 2022; 5:e2224892. [PMID: 35917124 PMCID: PMC9346548 DOI: 10.1001/jamanetworkopen.2022.24892] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Population-based data are needed to inform the safe prescribing of fluoroquinolone antibiotics to patients with advanced chronic kidney disease (CKD). OBJECTIVE To quantify the 14-day risk of a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or a collagen-associated event in patients with advanced CKD newly prescribed a fluoroquinolone at a higher vs a lower dose. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study in Ontario, Canada (January 1, 2008, to March 17, 2020) used linked health care data to identify new users of fluoroquinolone antibiotics. Participants included adults 66 years or older with advanced CKD (an estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2 but not receiving dialysis). Data analysis was performed from January 1 to April 30, 2021. EXPOSURES A new prescription for a higher-dose fluoroquinolone (ciprofloxacin, 501-1000 mg/d; levofloxacin, 501-750 mg/d; or norfloxacin, 401-800 mg/d) vs a lower-dose fluoroquinolone (ciprofloxacin, 500 mg/d; levofloxacin, 250-500 mg/d; or norfloxacin, 400 mg/d). MAIN OUTCOMES AND MEASURE The primary outcome was the 14-day risk of a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or a collagen-associated event. Secondary outcomes included a hospital visit with sepsis, retinal detachment or other tendinopathies, all-cause hospitalization, all-cause mortality, and sudden cardiac death. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on baseline health. Weighted risk ratios and risk differences were obtained using modified Poisson regression and binomial regression, respectively. RESULTS Of 11 917 patients (median age, 83 years [IQR, 77-89 years]; 7438 women [62.4%]; median eGFR, 25 [IQR, 21-28] mL/min/1.73 m2) included in the analysis, 5482 (46.0%) received a higher-dose and 6435 (54.0%) received a lower-dose fluoroquinolone. After weighting, the primary composite outcome-a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or a collagen-associated event-occurred in 68 of 5482 patients (1.2%) treated with a higher-dose fluoroquinolone and in 47 of 5516 (0.9%) treated with a lower-dose fluoroquinolone (weighted risk ratio, 1.45 [95% CI, 1.01-2.08]; weighted risk difference, 0.39% [95% CI, 0.01%-0.76%]). The risk of sepsis, retinal detachment, all-cause hospitalization, all-cause mortality, and sudden cardiac death did not differ significantly between groups. CONCLUSIONS AND RELEVANCE These findings suggest that older patients with advanced CKD who were prescribed a fluoroquinolone at a higher-than-recommended dose were significantly more likely to experience the composite outcome of a hospital visit with nervous system and/or psychiatric disorders, hypoglycemia, or a collagen-associated event, although the absolute risk of these events was less than 2%.
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Affiliation(s)
- Flory Tsobo Muanda
- ICES Western, Victoria Hospital, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Manish M. Sood
- ICES Western, Victoria Hospital, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Matthew A. Weir
- ICES Western, Victoria Hospital, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Jessica M. Sontrop
- Division of Nephrology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Fatemeh Ahmadi
- ICES Western, Victoria Hospital, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Elisa Yoo
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Richard B. Kim
- Division of Clinical Pharmacology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Michael S. Silverman
- Division of Infectious Diseases, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Gregory A. Knoll
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amit X. Garg
- ICES Western, Victoria Hospital, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Sheng G, Kuang M, Yang R, Zhong Y, Zhang S, Zou Y. Evaluation of the value of conventional and unconventional lipid parameters for predicting the risk of diabetes in a non-diabetic population. J Transl Med 2022; 20:266. [PMID: 35690771 PMCID: PMC9188037 DOI: 10.1186/s12967-022-03470-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conventional and unconventional lipid parameters are associated with diabetes risk, the comparative studies on lipid parameters for predicting future diabetes risk, however, are still extremely limited, and the value of conventional and unconventional lipid parameters in predicting future diabetes has not been evaluated. This study was designed to determine the predictive value of conventional and unconventional lipid parameters for the future development of diabetes. METHODS The study was a longitudinal follow-up study of 15,464 participants with baseline normoglycemia. At baseline, conventional lipid parameters such as low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C) were measured/calculated, and unconventional lipid parameters such as non-HDL-C, remnant cholesterol (RC), LDL/HDL-C ratio, TG/HDL-C ratio, non-HDL/HDL-C ratio, TC/HDL-C ratio and RC/HDL-C ratio were calculated. Hazard ratio (HR) and 95% confidence interval (CI) were estimated by Cox proportional hazard regression adjusting for demographic and diabetes-related risk factors. The predictive value and threshold fluctuation intervals of baseline conventional and unconventional lipid parameters for future diabetes were evaluated by the time-dependent receiver operator characteristics (ROC) curve. RESULTS The incidence rate of diabetes was 3.93 per 1000 person-years during an average follow-up period of 6.13 years. In the baseline non-diabetic population, only TG and HDL-C among the conventional lipid parameters were associated with future diabetes risk, while all the unconventional lipid parameters except non-HDL-C were significantly associated with future diabetes risk. In contrast, unconventional lipid parameters reflected diabetes risk better than conventional lipid parameters, and RC/HDL-C ratio was the best lipid parameter to reflect the risk of diabetes (HR: 6.75, 95% CI 2.40-18.98). Sensitivity analysis further verified the robustness of this result. Also, time-dependent ROC curve analysis showed that RC, non-HDL/HDL-C ratio, and TC/HDL-C ratio were the best lipid parameters for predicting the risk of medium-and long-term diabetes. CONCLUSIONS Unconventional lipid parameters generally outperform conventional lipid parameters in assessing and predicting future diabetes risk. It is suggested that unconventional lipid parameters should also be routinely evaluated in clinical practice.
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Affiliation(s)
- Guotai Sheng
- Department of Cardiology, Jiangxi Provincial People's Hospital, Nanchang, 330006, Jiangxi, China
| | - Maobin Kuang
- Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Ruijuan Yang
- Medical College of Nanchang University, Nanchang, 330006, Jiangxi, China.,Department of Endocrinology, Jiangxi Provincial People's Hospital, Nanchang, 330006, Jiangxi, China
| | - Yanjia Zhong
- Department of Endocrinology, Jiangxi Provincial People's Hospital, Nanchang, 330006, Jiangxi, China
| | - Shuhua Zhang
- Jiangxi Provincial People's Hospital, Jiangxi Cardiovascular Research Institute, Nanchang, 330006, Jiangxi, China
| | - Yang Zou
- Jiangxi Provincial People's Hospital, Jiangxi Cardiovascular Research Institute, Nanchang, 330006, Jiangxi, China.
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Muanda FT, Weir MA, Ahmadi F, Sontrop JM, Cowan A, Fleet JL, Blake PG, Garg AX. Higher-Dose Gabapentinoids and the Risk of Adverse Events in Older Adults With CKD: A Population-Based Cohort Study. Am J Kidney Dis 2021; 80:98-107.e1. [PMID: 34979160 DOI: 10.1053/j.ajkd.2021.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 11/02/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Gabapentinoids are an opioid substitute whose elimination by the kidneys is reduced as kidney function declines. To inform their safe prescribing in older adults with chronic kidney disease (CKD), we examined the 30-day risk of serious adverse events according to the prescribed starting dose. STUDY DESIGN Population-based cohort study. SETTING & PARTICIPANTS 74,084 older adults (64% women; median age 79 [interquartile range 73-85]) with CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73m2 while not receiving dialysis) and a newly prescribed a gabapentinoid between 2008-2020 in Ontario, Canada. EXPOSURE Higher-dose gabapentinoids (gabapentin >300 mg/day or pregabalin >75 mg/day) vs lower-dose gabapentinoids (gabapentin ≤300 mg/day or pregabalin ≤75 mg/day). OUTCOMES The primary composite outcome was the 30-day risk of a hospital visit with encephalopathy, a fall, a fracture, or a hospitalization with respiratory depression. ANALYTICAL APPROACH Comparison groups were balanced on indicators of baseline health using inverse probability of treatment weighting using propensity score analysis that generated a pseudo-sample for the reference group with a distribution of measured covariates similar to the exposed group. Weighted risk ratios (RR) were estimated using modified Poisson regression, and weighted risk differences (RD) estimated using binomial regression. Pre-specified subgroup analyses were conducted by eGFR category and type of gabapentinoid. RESULTS Among 74,084 patients were identified with CKD and a new prescription for gabapentin or pregabalin 41% started at >300 mg/day and >75 mg/day, respectively. From this set of patients a weighted study population with a size of 61,367 was generated. Patients who started at a higher dose had a 30-day risk of the primary outcome higher than the risk among with patients who started at lower dose. Within the weighted population, the numbers of events for higher vs. lower dose were 585/30,660 [1.9%] vs 462/30,707 [1.5%], respectively. The weighted RR was 1.27 [95% CI, 1.13 to 1.42] and the weighted RD was 0.40% [95% CI, 0.21% to 0.60%]). In subgroup analyses, neither multiplicative nor additive interactions were statistically significant. LIMITATIONS Residual confounding. CONCLUSIONS In this population-based study, starting a gabapentinoid at a higher vs lower dose was associated with a slightly higher risk of a hospital stay with encephalopathy, a fall, or a fracture, or hospitalization with respiratory depression. If verified, these risks should be balanced against the benefits of using a higher-dose gabapentinoid.
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Affiliation(s)
- Flory T Muanda
- ICES Western, London ON, Canada; Department of Epidemiology & Biostatistics, Western University, London ON, Canada.
| | - Matthew A Weir
- ICES Western, London ON, Canada; Department of Epidemiology & Biostatistics, Western University, London ON, Canada; Division of Nephrology, Department of Medicine, Western University, London ON, Canada
| | - Fatemeh Ahmadi
- ICES Western, London ON, Canada; Department of Epidemiology & Biostatistics, Western University, London ON, Canada
| | - Jessica M Sontrop
- Department of Epidemiology & Biostatistics, Western University, London ON, Canada
| | - Andrea Cowan
- ICES Western, London ON, Canada; Department of Epidemiology & Biostatistics, Western University, London ON, Canada; Division of Nephrology, Department of Medicine, Western University, London ON, Canada
| | - Jamie L Fleet
- Department of Physical Medicine and Rehabilitation, Western University, London ON, Canada
| | - Peter G Blake
- Division of Nephrology, Department of Medicine, Western University, London ON, Canada
| | - Amit X Garg
- ICES Western, London ON, Canada; Department of Epidemiology & Biostatistics, Western University, London ON, Canada; Division of Nephrology, Department of Medicine, Western University, London ON, Canada
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Recommendations from the EXTRIP workgroup on extracorporeal treatment for baclofen poisoning. Kidney Int 2021; 100:720-736. [PMID: 34358487 DOI: 10.1016/j.kint.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 06/04/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Baclofen toxicity results from intentional self-poisoning ("acute baclofen poisoning") or accumulation of therapeutic dose in the setting of impaired kidney function. Standard care includes baclofen discontinuation, respiratory support and seizure treatment. Use of extracorporeal treatments (ECTRs) is controversial. To clarify this, a comprehensive review of the literature on the effect of ECTRs in baclofen toxicity was performed and recommendations following EXTRIP methods were formulated based on 43 studies. (1 comparative cohort, 1 aggregate results cohort, 1 pharmacokinetic modeling, and 40 patient reports or series). Toxicokinetic data were available for 20 patients. Baclofen's dialyzability is limited by a high endogenous clearance and a short half-life in patients with normal kidney function. The workgroup assessed baclofen as "Moderately dialyzable" by intermittent hemodialysis for patients with normal kidney function (quality of evidence C) and "Dialyzable" for patients with impaired kidney function (quality of evidence C). Clinical data were available for 25 patients with acute baclofen poisoning and 46 patients with toxicity from therapeutic baclofen in kidney impairment. No deaths or sequelae were reported. Mortality in historical controls was rare. No benefit of ECTR was identified in patients with acute baclofen poisoning. Indirect evidence suggests a benefit of ECTR in reducing the duration of toxic encephalopathy from therapeutic baclofen in kidney impairment. These potential benefits were balanced against added costs and harms related to the insertion of a catheter, the procedure itself, and the potential of baclofen withdrawal. Thus, the EXTRIP workgroup suggests against performing ECTR in addition to standard care for acute baclofen poisoning and suggests performing ECTR in toxicity from therapeutic baclofen in kidney impairment, especially in the presence of coma requiring mechanical ventilation.
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Mohottige D, Manley HJ, Hall RK. Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review. KIDNEY360 2021; 2:1510-1522. [PMID: 35373095 PMCID: PMC8786141 DOI: 10.34067/kid.0001942021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
Due to age and impaired kidney function, older adults with kidney disease are at increased risk of medication-related problems and related hospitalizations. One proa ctive approach to minimize this risk is deprescribing. Deprescribing refers to the systematic process of reducing or stopping a medication. Aside from preventing harm, deprescribing can potentially optimize patients' quality of life by aligning medications with their goals of care. For some patients, deprescribing could involve less aggressive management of their diabetes and/or hypertension. In other instances, deprescribing targets may include potentially inappropriate medications that carry greater risk of harm than benefit in older adults, medications that have questionable efficacy, including medications that have varying efficacy by degree of kidney function, and that increase medication regimen complexity. We include a guide for clinicians to utilize in deprescribing, the List, Evaluate, Shared Decision-Making, Support (LESS) framework. The LESS framework provides key considerations at each step of the deprescribing process that can be tailored for the medications and context of individu al patients. Patient characteristics or clinical events that warrant consideration of deprescribing include limited life expectancy, cognitive impairment, and health status changes, such as dialysis initiation or recent hospitalization. We acknowledge patient-, clinician-, and system-level challenges to the depre scribing process. These include patient hesitancy and challenges to discussing goals of care, clinician time constraints and a lack of evidence-based guidelines, and system-level challenges of interoperable electronic health records and limited incentives for deprescribing. However, novel evidence-based tools designed to facilitate deprescribing and future evidence on effectiveness of deprescribing could help mitigate these barriers. This review provides foundational knowledge on deprescribing as an emerging component of clinical practice and research within nephrology.
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Affiliation(s)
- Dinushika Mohottige
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Rasheeda K. Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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29
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Mitsuboshi S. Association Between Baclofen and Respiratory Depression in Patients With Chronic Kidney Disease. J Clin Pharmacol 2021; 61:836-837. [PMID: 33629349 DOI: 10.1002/jcph.1843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/19/2021] [Indexed: 11/10/2022]
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30
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Shlipak MG, Tummalapalli SL, Boulware LE, Grams ME, Ix JH, Jha V, Kengne AP, Madero M, Mihaylova B, Tangri N, Cheung M, Jadoul M, Winkelmayer WC, Zoungas S. The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2021; 99:34-47. [PMID: 33127436 DOI: 10.1016/j.kint.2020.10.012] [Citation(s) in RCA: 212] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023]
Abstract
Chronic kidney disease (CKD) causes substantial global morbidity and increases cardiovascular and all-cause mortality. Unlike other chronic diseases with established strategies for screening, there has been no consensus on whether health systems and governments should prioritize early identification and intervention for CKD. Guidelines on evaluating and managing early CKD are available but have not been universally adopted in the absence of incentives or quality measures for prioritizing CKD care. The burden of CKD falls disproportionately upon persons with lower socioeconomic status, who have a higher prevalence of CKD, limited access to treatment, and poorer outcomes. Therefore, identifying and treating CKD at the earliest stages is an equity imperative. In 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a controversies conference entitled "Early Identification and Intervention in CKD." Participants identified strategies for screening, risk stratification, and treatment for early CKD and the key health system and economic factors for implementing these processes. A consensus emerged that CKD screening coupled with risk stratification and treatment should be implemented immediately for high-risk persons and that this should ideally occur in primary or community care settings with tailoring to the local context.
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Affiliation(s)
- Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco, San Francisco, California, USA; General Internal Medicine Division, Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.
| | - Sri Lekha Tummalapalli
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco, San Francisco, California, USA; General Internal Medicine Division, Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - L Ebony Boulware
- Department of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Morgan E Grams
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA; Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California, USA; Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales, New Delhi, India; University of Oxford, Oxford, UK; Department of Nephrology, Manipal Academy of Higher Education, Manipal, India
| | - Andre-Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Magdalena Madero
- Department of Medicine, Division of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Institute of Population Health Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Navdeep Tangri
- Department of Community Health Services, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes, Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Sophia Zoungas
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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Muanda FT, Weir MA, Bathini L, Clemens KK, Perkovic V, Sood MM, McArthur E, Sontrop JM, Kim RB, Garg AX. Higher-Dose Sitagliptin and the Risk of Congestive Heart Failure in Older Adults with CKD. Clin J Am Soc Nephrol 2020; 15:1728-1739. [PMID: 33239410 PMCID: PMC7769019 DOI: 10.2215/cjn.08310520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/17/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Sitagliptin, a dipeptidyl peptidase-4 inhibitor, is commonly prescribed to patients with type 2 diabetes. As this drug is primarily eliminated by the kidney, a reduced dose is recommended for patients with CKD. Some evidence suggests that sitagliptin is associated with a higher risk of congestive heart failure, particularly at higher doses. We compare the 1-year risk of death or hospitalization with congestive heart failure in patients with CKD newly prescribed sitagliptin at >50 versus ≤50 mg/d. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This population-based cohort study included older adults (>66 years) with type 2 diabetes and an eGFR<45 ml/min per 1.73 m2 (but not receiving dialysis) who were newly prescribed sitagliptin between 2010 and 2017 in Ontario, Canada. We used inverse probability of treatment weighting on the basis of propensity scores to balance baseline characteristics. The primary composite outcome was death or hospitalization with congestive heart failure. Secondary outcomes included hospitalization with pancreatitis or hypoglycemia, all-cause hospitalization, and glycemic control. Weighted hazard ratios were obtained using Cox proportional hazards regression, and 95% confidence intervals were obtained using bootstrap variance estimators. RESULTS Of 9215 patients, 6518 started sitagliptin at >50 mg/d, and 2697 started sitagliptin at ≤50 mg/d. The 1-year risk of death or hospitalization with congestive heart failure did not differ significantly between groups (79 versus 126 events per 1000 person-years; weighted hazard ratio, 0.88; 95% confidence interval, 0.67 to 1.14); hospitalization with pancreatitis (weighted hazard ratio, 0.98; 95% confidence interval, 0.32 to 3.03) and hypoglycemia (weighted hazard ratio, 1.10; 95% confidence interval, 0.64 to 1.90) also did not differ significantly between groups. Patients starting sitagliptin at >50 mg/d had lower mean glycated hemoglobin concentrations (weighted between-group difference, -0.12%; 95% confidence interval, -0.19 to -0.06) and a lower risk of all-cause hospitalization (weighted hazard ratio, 0.81; 95% confidence interval, 0.66 to 0.98). CONCLUSIONS The risk of death or congestive heart failure was not higher in older adults with CKD starting sitagliptin at >50 versus ≤50 mg/d. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_11_25_CJN08310520_final.mp3.
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Affiliation(s)
- Flory T Muanda
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada .,Department of Epidemiology and Biostatistics, Western University, London, Canada
| | - Matthew A Weir
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Canada
| | - Lavanya Bathini
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Canada
| | - Kristin K Clemens
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, Canada
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Manish M Sood
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
| | - Eric McArthur
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada
| | - Jessica M Sontrop
- Division of Nephrology, Department of Medicine, Western University, London, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
| | - Amit X Garg
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Canada
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Chauvin KJ, Blake PG, Garg AX, Weir MA, Bathini L, Dixon SN, McArthur E, Sontrop JM, Moist L, Kim RB, Muanda FT. Baclofen has a risk of encephalopathy in older adults receiving dialysis. Kidney Int 2020; 98:979-988. [DOI: 10.1016/j.kint.2020.04.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/16/2020] [Accepted: 04/24/2020] [Indexed: 12/23/2022]
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Norouzi S, Farouk SS, Sparks MA. Back off baclofen when the kidneys don’t work. Kidney Int 2020; 98:829-831. [DOI: 10.1016/j.kint.2020.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 05/20/2020] [Indexed: 11/29/2022]
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Lee VR, Shively RM, Connolly MK, Hoffman RS, Nogar J. Removal of baclofen with hemodialysis is negligible compared to intact kidney excretion in a pediatric overdose: a case report. Clin Toxicol (Phila) 2020; 59:231-234. [PMID: 32734785 DOI: 10.1080/15563650.2020.1795188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Severe baclofen toxicity can result in respiratory failure, hemodynamic instability, bradycardia, hypothermia, seizures, coma, and death. While hemodialysis (HD) is well-described in treating acute baclofen toxicity in patients with end-stage kidney disease or acute kidney injury, the utility of HD for patients with normal kidney function is uncertain. Implementing HD to speed recovery after a large acute baclofen ingestion is appealing, considering: (a) potential for prolonged coma and ventilator-associated morbidity, and (b) baclofen's low protein-binding, low molecular-weight, and moderate volume of distribution. METHODS We report a 51 kg, 14-year-old girl who presented to the emergency department (ED) with hypotension, obtundation, and status epilepticus after an intentional ingestion of 1200 mg baclofen. Her post-intubation neurologic examination was concerning for coma. A 14-hour post-ingestion baclofen concentration was 882 ng/mL (therapeutic range 80-400 ng/mL). Three urgent-HD sessions were performed to reduce her time on the ventilator. RESULTS The total baclofen removed in the first three-hour HD session was 3.05 mg. The total urinary elimination of baclofen 42 mg over 24-hours on day one. She was discharged without neurologic deficits to psychiatry on day-14. CONCLUSION In this case, the amount of baclofen recovered during HD is negligible in comparison to the amount cleared by kidney elimination in this patient with normal kidney function.
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Affiliation(s)
- Vincent R Lee
- Department of Emergency Medicine, Division of Medical Toxicology, Northwell Health, Manhasset, NY, USA
| | - Rachel M Shively
- Department of Emergency Medicine, Division of Medical Toxicology, Northwell Health, Manhasset, NY, USA
| | - Michael K Connolly
- Department of Emergency Medicine, Division of Medical Toxicology, Northwell Health, Manhasset, NY, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Joshua Nogar
- Department of Emergency Medicine, Division of Medical Toxicology, Northwell Health, Manhasset, NY, USA
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Reynoard J, Schmitt C, Torrents R, Simon N. Toxicological considerations in the prescription of baclofen for the treatment of substance use disorders. Expert Opin Drug Metab Toxicol 2020; 16:309-317. [PMID: 32149546 DOI: 10.1080/17425255.2020.1740681] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: For many years, applications for baclofen have widened in the treatment of substance abuse disorder (SUD), mainly alcohol use disorder, with a growing rate of off-label prescriptions in Europe. Clinical effects seem to be both a decrease of craving and anxiety, leading to a decrease of drug or alcohol consumption. We described baclofen poisoning circumstances, therapeutic options and outcomes when used in substance use disorders.Areas covered: This review summarizes the toxicological considerations where baclofen was prescribed in humans for substance use or abuse disorder in randomized clinical trials, case series, case reports and observational studies between 1990 and 2020 according to the Preferred Reporting Items for Systemic reviews and Meta-Analysis.Expert opinion: The most frequent cause of severe intoxication is self-poisoning. A dose above 180 mg are expected to cause severe toxicity and death. The treatment is only symptomatic as no antidote is available. Off-label prescription remains unsafe because the optimal dose is not known and varies greatly between patients. As SUD are frequently associated with psychiatric disorders and such patients may have suicidal thoughts, the risk of self-poisoning is high. Potential co-ingestants should also be considered, especially CNS depressants, and they need to be closely monitored.
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Affiliation(s)
- Julien Reynoard
- Pharmacologie Clinique CAP-TV, APHM, Hôpitaux Sud, Marseille, France
| | - Corinne Schmitt
- Pharmacologie Clinique CAP-TV, APHM, Hôpitaux Sud, Marseille, France
| | - Romain Torrents
- APHM, INSERM, IRD, SESSTIM, Hôpital Sainte Marguerite Pharmacologie Clinique CAP-TV, Aix Marseille Univ, Marseille, France
| | - Nicolas Simon
- APHM, INSERM, IRD, SESSTIM, Hôpital Sainte Marguerite Pharmacologie Clinique CAP-TV, Aix Marseille Univ, Marseille, France
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Taji L, Battistella M, Grill AK, Cunningham J, Hemmelgarn BL, Quinn KM, Thomas A, Brimble KS. Medications Used Routinely in Primary Care to be Dose-Adjusted or Avoided in People With Chronic Kidney Disease: Results of a Modified Delphi Study. Ann Pharmacother 2020; 54:625-632. [DOI: 10.1177/1060028019897371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Chronic kidney disease (CKD) affects up to 18% of those over the age of 65 years. Potentially inappropriate medication prescribing in people with CKD is common. Objectives: Develop a pragmatic list of medications used in primary care that required dose adjustment or avoidance in people with CKD, using a modified Delphi panel approach, followed by a consensus workshop. Methods: We conducted a comprehensive literature search to identify potential medications. A group of 17 experts participated in a 3-round modified Delphi panel to identify medications for inclusion. A subsequent consensus workshop of 8 experts reviewed this list to prioritize medications for the development of point-of-care knowledge translation materials for primary care. Results: After a comprehensive literature review, 59 medications were included for consideration by the Delphi panel, with a further 10 medications added after the initial round. On completion of the 3 Delphi rounds, 66 unique medications remained, 63 requiring dose adjustment and 16 medications requiring avoidance in one or more estimated glomerular filtration rate categories. The consensus workshop prioritized this list further to 24 medications that must be dose-adjusted or avoided, including baclofen, metformin, and digoxin, as well as the newer SGLT2 inhibitor agents. Conclusion and Relevance: We have developed a concise list of 24 medications commonly used in primary care that should be dose-adjusted or avoided in people with CKD to reduce harm. This list incorporates new and frequently prescribed medications and will inform an updated, easy to access source for primary care providers.
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Affiliation(s)
- Leena Taji
- Ontario Renal Network, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Marisa Battistella
- University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Allan K. Grill
- University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Jessie Cunningham
- Ontario Renal Network, Cancer Care Ontario, Toronto, Ontario, Canada
| | | | | | - Ann Thomas
- Ontario Renal Network, Cancer Care Ontario, Toronto, Ontario, Canada
| | - K. Scott Brimble
- Ontario Renal Network, Cancer Care Ontario, Toronto, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
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