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Liu J, Luo C, Guo Y, Cao F, Yan J. Individual trigger factors for hemorrhagic stroke: Evidence from case-crossover and self-controlled case series studies. Eur Stroke J 2023; 8:808-818. [PMID: 37641550 PMCID: PMC10472950 DOI: 10.1177/23969873231173285] [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: 02/27/2023] [Accepted: 04/12/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Hemorrhagic stroke (HS) is a sudden-onset disease with high mortality and disability rates, and it is crucial to explore the triggers of HS. In this study, we analyzed individual triggers for HS to provide a basis for HS prevention and intervention. METHODS A systematic search of five databases was conducted until December 2022. Studies on HS-related individual triggers conducted using a case-crossover study or self-controlled case series design were included in the descriptive summary and comprehensive evidence synthesis of each trigger. RESULTS A total of 39 studies were included after the screening, and 32 trigger factor categories were explored for associations. Potential trigger factors for HS were as follows: Antiplatelet (odd ratio (OR), 1.10; 95% confidence interval (CI), 1.00-1.21) and anticoagulant (OR, 5.43; 95% CI, 2.04-14.46) medications, mood stabilizers/antipsychotics (OR, 1.33; 95% CI, 1.07-1.65), infections (OR, 2.15; 95% CI, 1.73-2.67), vaccinations (relative risk, 1.11; 95% CI, 1.02-1.21), physical exertion (OR, 2.08; 95% CI, 1.58-2.74), cola consumption (OR, 5.45; 95% CI, 2.76-10.76), sexual activity (OR, 7.49; 95% CI, 2.23-25.22), nose blowing (OR range, 2.40-56.40), defecation (OR, 16.94; 95% CI, 3.40-84.37), and anger (OR, 3.59; 95% CI, 1.56-8.26). No associations were observed with illicit drug use (OR, 2.05; 95% CI, 0.52-8.06) or cigarette smoking (OR, 0.81; 95% CI, 0.52-1.24) and HS. CONCLUSIONS Individual triggers, including several medications, infections, vaccinations, and behaviors, may trigger HS onset. Direct control measures for behavioral triggers can play a crucial role in preventing HS. High-risk populations should receive personalized therapies and monitoring measures during the medication treatment to balance the risk of acute HS and the basic diseases.
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Affiliation(s)
- Junyu Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Department of Pharmacology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Chun Luo
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Yuxin Guo
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Fang Cao
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Junxia Yan
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, Central South University, Changsha, China
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Chen C, Hennessy S, Brensinger CM, Dawwas GK, Acton EK, Bilker WB, Chung SP, Dublin S, Horn JR, Miano TA, Pham Nguyen TP, Soprano SE, Leonard CE. Skeletal muscle relaxant drug-drug-drug interactions and unintentional traumatic injury: Screening to detect three-way drug interaction signals. Br J Clin Pharmacol 2022; 88:4773-4783. [PMID: 35562168 PMCID: PMC9560998 DOI: 10.1111/bcp.15395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/27/2022] Open
Abstract
AIM The aim of this study was to identify skeletal muscle relaxant (SMR) drug-drug-drug interaction (3DI) signals associated with increased rates of unintentional traumatic injury. METHODS We conducted automated high-throughput pharmacoepidemiologic screening of 2000-2019 healthcare data for members of United States commercial and Medicare Advantage health plans. We performed a self-controlled case series study for each drug triad consisting of an SMR base-pair (i.e., concomitant use of an SMR with another medication), and a co-dispensed medication (i.e., candidate interacting precipitant) taken during ongoing use of the base-pair. We included patients aged ≥16 years with an injury occurring during base-pair-exposed observation time. We used conditional Poisson regression to calculate adjusted rate ratios (RRs) with 95% confidence intervals (CIs) for injury with each SMR base-pair + candidate interacting precipitant (i.e., triad) versus the SMR-containing base-pair alone. RESULTS Among 58 478 triads, 29 were significantly positively associated with injury; confounder-adjusted RRs ranged from 1.39 (95% CI = 1.01-1.91) for tizanidine + omeprazole with gabapentin to 2.23 (95% CI = 1.02-4.87) for tizanidine + diclofenac with alprazolam. Most identified 3DI signals are new and have not been formally investigated. CONCLUSION We identified 29 SMR 3DI signals associated with increased rates of injury. Future aetiologic studies should confirm or refute these SMR 3DI signals.
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Affiliation(s)
- Cheng Chen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Ghadeer K. Dawwas
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
| | - Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | | | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute (Seattle, WA, US)
- Department of Epidemiology, School of Public Health, University of Washington (Seattle, WA, US)
| | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington (Seattle, WA, US)
| | - Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Thanh Phuong Pham Nguyen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Samantha E. Soprano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
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Population-based screening to detect benzodiazepine drug-drug-drug interaction signals associated with unintentional traumatic injury. Sci Rep 2022; 12:15569. [PMID: 36114250 PMCID: PMC9481644 DOI: 10.1038/s41598-022-19551-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/31/2022] [Indexed: 11/08/2022] Open
Abstract
AbstractDrug interactions involving benzodiazepines and related drugs (BZDs) are increasingly recognized as a contributor to increased risk of unintentional traumatic injury. Yet, it remains unknown to what extent drug interaction triads (3DIs) may amplify BZDs’ inherent injury risk. We identified BZD 3DI signals associated with increased injury rates by conducting high-throughput pharmacoepidemiologic screening of 2000–2019 Optum’s health insurance data. Using self-controlled case series design, we included patients aged ≥ 16 years with an injury while using a BZD + co-dispensed medication (i.e., base pair). During base pair-exposed observation time, we identified other co-dispensed medications as candidate interacting precipitants. Within each patient, we compared injury rates during time exposed to the drug triad versus to the base pair only using conditional Poisson regression, adjusting for time-varying covariates. We calculated rate ratios (RRs) with 95% confidence intervals (CIs) and accounted for multiple estimation via semi-Bayes shrinkage. Among the 65,123 BZD triads examined, 79 (0.1%) were associated with increased injury rates and considered 3DI signals. Adjusted RRs for signals ranged from 3.01 (95% CI = 1.53–5.94) for clonazepam + atorvastatin with cefuroxime to 1.42 (95% CI = 1.00–2.02, p = 0.049) for alprazolam + hydrocodone with tizanidine. These signals may help researchers prioritize future etiologic studies to investigate higher-order BZD interactions.
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Efficacy and Safety of Direct Oral Anticoagulants in Patients with Diabetes and Nonvalvular Atrial Fibrillation: Meta-Analysis of Observational Studies. Cardiovasc Ther 2021; 2021:5520027. [PMID: 34729079 PMCID: PMC8523231 DOI: 10.1155/2021/5520027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/08/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
Background This meta-analysis was performed to compare the efficacy and safety of direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) for stroke prevention in real-world patients with diabetes and nonvalvular atrial fibrillation (NVAF) through observational studies. Methods PubMed, Embase, and Web of Science databases were searched up to August 2020 for eligible studies. Outputs were presented as risk ratios (RRs) and corresponding 95% confidence intervals (CIs) by using a random-effect model. Results Seven observational studies involving 249,794 diabetic NVAF patients were selected. Compared with VKAs, the use of DOACs was associated with significantly reduced risks of stroke (RR = 0.56, 95% CI 0.45-0.70; p < 0.00001), ischemic stroke (RR = 0.61, 95% CI 0.48-0.78; p < 0.0001), stroke or systemic embolism (SSE) (RR = 0.81, 95% CI 0.68-0.95; p = 0.01), myocardial infarction (RR = 0.69, 95% CI 0.55-0.88; p = 0.002), major bleeding (RR = 0.75, 95% CI 0.63-0.90; p = 0.002), intracranial hemorrhage (RR = 0.50, 95% CI 0.44-0.56; p < 0.00001), and major gastrointestinal bleeding (RR = 0.77, 95% CI 0.62-0.95; p = 0.02), and a borderline significant decrease in major adverse cardiac events (RR = 0.87, 95% CI 0.75-1.00; p = 0.05) in NVAF patients with diabetes. Conclusion For patients with NVAF and diabetes in real-world clinical settings, DOACs showed superior efficacy and safety profile over VKAs and significantly reduced risks of stroke, ischemic stroke, SSE, myocardial infarction, major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding.
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