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Htoo PT, Tesfaye H, Schneeweiss S, Wexler DJ, Everett BM, Glynn RJ, Schmedt N, Koeneman L, Déruaz-Luyet A, Paik JM, Patorno E. Effectiveness and safety of empagliflozin: final results from the EMPRISE study. Diabetologia 2024; 67:1328-1342. [PMID: 38509341 DOI: 10.1007/s00125-024-06126-3] [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: 10/18/2023] [Accepted: 02/05/2024] [Indexed: 03/22/2024]
Abstract
AIMS/HYPOTHESIS Limited evidence exists on the comparative safety and effectiveness of empagliflozin against alternative glucose-lowering medications in individuals with type 2 diabetes with the broad spectrum of cardiovascular risk. The EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) cohort study was designed to monitor the safety and effectiveness of empagliflozin periodically for a period of 5 years with data collection from electronic healthcare databases. METHODS We identified individuals ≥18 years old with type 2 diabetes who initiated empagliflozin or dipeptidyl peptidase-4 inhibitors (DPP-4i) from 2014 to 2019 using US Medicare and commercial claims databases. After 1:1 propensity score matching using 143 baseline characteristics, we identified four a priori-defined effectiveness outcomes: (1) myocardial infarction (MI) or stroke; (2) hospitalisation for heart failure (HHF); (3) major adverse cardiovascular events (MACE); and (4) cardiovascular mortality or HHF. Safety outcomes included lower-limb amputations, non-vertebral fractures, diabetic ketoacidosis (DKA), acute kidney injury (AKI), severe hypoglycaemia, retinopathy progression, and short-term kidney and bladder cancers. We estimated HRs and rate differences (RDs) per 1000 person-years, overall and stratified by age, sex, baseline atherosclerotic cardiovascular disease (ASCVD) and heart failure. RESULTS We identified 115,116 matched pairs. Compared with DPP-4i, empagliflozin was associated with lower risks of MI/stroke (HR 0.88 [95% CI 0.81, 0.96]; RD -2.08 [95% CI (-3.26, -0.90]), HHF (HR 0.50 [0.44, 0.56]; RD -5.35 [-6.22, -4.49]), MACE (HR 0.73 [0.62, 0.86]; RD -6.37 [-8.98, -3.77]) and cardiovascular mortality/HHF (HR 0.57 [0.47, 0.69]; RD -10.36 [-12.63, -8.12]). Absolute benefits were larger in older individuals and in those with ASCVD/heart failure. Empagliflozin was associated with an increased risk of DKA (HR 1.78 [1.44, 2.19]; RD 1.59 [1.08, 2.09]); decreased risks of AKI (HR 0.62 [0.54, 0.72]; RD -2.39 [-3.08, -1.71]), hypoglycaemia (HR 0.75 [0.67, 0.84]; RD -2.46 [-3.32, -1.60]) and retinopathy progression (HR 0.78 [0.63, 0.96)]; RD -9.49 [-16.97, -2.10]); and similar risks of other safety events. CONCLUSIONS/INTERPRETATION Empagliflozin relative to DPP-4i was associated with risk reductions of MI or stroke, HHF, MACE and the composite of cardiovascular mortality or HHF. Absolute risk reductions were larger in older individuals and in those who had history of ASCVD or heart failure. Regarding the safety outcomes, empagliflozin was associated with an increased risk of DKA and lower risks of AKI, hypoglycaemia and progression to proliferative retinopathy, with no difference in the short-term risks of lower-extremity amputation, non-vertebral fractures, kidney and renal pelvis cancer, and bladder cancer.
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Affiliation(s)
- Phyo T Htoo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Helen Tesfaye
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Brendan M Everett
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niklas Schmedt
- Global Epidemiology, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Lisette Koeneman
- Global Medical Affairs, Lilly Deutschland GmbH, Bad Homburg vor der Höhe, Germany
| | - Anouk Déruaz-Luyet
- Global Epidemiology, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Division of Renal (Kidney) Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Kwon Y, Lauffenburger JC. Antidepressant discontinuation patterns and characteristics across sociodemographic groups in the United States. J Affect Disord 2024; 355:82-85. [PMID: 38554879 DOI: 10.1016/j.jad.2024.03.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND While antidepressants are frequently used, less is known about contemporary discontinuation patterns, especially across different sociodemographic populations. METHODS Patients 16-84 years initiating antidepressants between 2016 and 2019 within a large US health insurer were identified. The association between patient characteristics and time until antidepressant discontinuation was evaluated using adjusted Cox proportional hazard regression. RESULTS Across 1,365,576 patients, mean time to discontinuation was 168.1 days (SD: 223.6). Men were more likely to discontinue than women (HR: 0.94, 95%CI: 0.94-0.94). Younger patients (16-24 years) were more likely to discontinue than older patients. Patients who were non-White (Asian HR: 1.33, 95%CI: 1.31-1.34; Black HR: 1.27, 95%CI: 1.27-1.28; Hispanic HR: 1.34, 95%:CI 1.34-1.35), with evidence of a substance use disorder (HR: 1.31, 95%CI: 1.27-1.35), or taking tricyclic antidepressants (HR:1.26, 95%CI: 1.25-1.27) were more likely to discontinue. LIMITATIONS Information on reasons for discontinuation was not available, and wide standard deviations for the primary outcome were reported. The results may not be generalized to non-commercially insured beneficiaries. CONCLUSIONS Discontinuation is common within the first 6 months of treatment but varies across populations, highlighting patients who may benefit from potential intervention.
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Affiliation(s)
- Yoojung Kwon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, United States of America; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, United States of America
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, United States of America.
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Back S, Knox B, Coakley C, Deltour N, Jacquot E, Raad H, Garry EM. Effectiveness and Safety of the MVA-BN Vaccine against Mpox in At-Risk Individuals in the United States (USMVAc). Vaccines (Basel) 2024; 12:651. [PMID: 38932380 PMCID: PMC11209565 DOI: 10.3390/vaccines12060651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/31/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
The mpox 2022 outbreak was declared a public health emergency in July 2022. In August 2022, the MVA-BN vaccine received emergency use authorization in the United States (US) to target at-risk groups. This study (EUPAS104386) used HealthVerity's administrative US healthcare data to generate real-world evidence for MVA-BN vaccine effectiveness and safety to prevent mpox disease in men who have sex with men (MSM) and transgender women, the most affected population during the 2022 mpox outbreak. Fully vaccinated subjects (two doses ≥ 28 days apart) were initially matched with five unvaccinated subjects on calendar date, age, US region, and insurance type. Subjects were followed from index date (14 days after the second dose) until death or data end to ascertain mpox occurrence. After propensity score adjustment, the MVA-BN vaccine effectiveness against mpox disease was 89% (95% CI: 12%, 99%) among those fully vaccinated; attenuated to 64% (95% CI: 40%, 78%) among those with any dose and 70% (95% CI: 44%, 84%) for those with only a single dose. One pericarditis adverse event of special interest was observed when the risk window was extended to 28 days. These results contribute to the totality of evidence supporting the favorable benefit/risk profile of the MVA-BN vaccine.
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Viguier M, Bentayeb M, Azzi J, de Pouvourville G, Gloede T, Langellier B, Massol J, Medina P, Thoma C, Bachelez H. Generalized pustular psoriasis: A nationwide population-based study using the National Health Data System in France. J Eur Acad Dermatol Venereol 2024; 38:1131-1139. [PMID: 38404163 DOI: 10.1111/jdv.19901] [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: 05/26/2023] [Accepted: 01/24/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND GPP is a rare, chronic, neutrophilic skin disease, with limited real-world data characterizing patients with flares and the impact of flares on disease progression and morbidity. OBJECTIVE Describe the clinical characteristics of patients with GPP, comorbidities, disease epidemiology and frequency and severity of flares, and compare patients with GPP with a matched severe psoriasis population. METHODS In this population-based real-world cohort study an algorithm was developed to identify patients with GPP flares. Three cohorts were identified using the Système National des Données de Santé (SNDS) database covering almost the entire French population; a prevalent cohort (2010-2018), an incident cohort (2012-2015). A severe psoriasis cohort was compared with the GPP incident cohort using propensity score matching. RESULTS The prevalent and incident cohorts comprised 4195 and 1842 patients, respectively. In both cohorts, mean age was 58 years; 53% were male. Comorbidities were significantly more common in the incident cohort versus matched psoriasis cohort, respectively, including hypertension (44% vs. 26%), ischaemic heart disease (26% vs. 18%) and hyperlipidaemia (25% vs. 15%). In the incident cohort, the flare rate was 0.1 flares/person-year and 0.4 flares/person-year among the 569 out of 1842 patients hospitalized with flares. These patients had a mean (±SD) stay of 11.6 ± 10.4 days; 25% were admitted to the intensive care unit. In 2017, the cumulative incidence and cumulative GPP age-sex standardized prevalence were 7.1 and 45.2 per million, respectively. CONCLUSIONS Patients with GPP had a distinct comorbidity profile compared to patients with severe psoriasis, and GPP flares were associated with long hospitalizations.
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Affiliation(s)
- Manuelle Viguier
- Department of Dermatology-Venereology, Hôpital Robert Debré and Université Reims-Champagne Ardenne, IRMAIC, EA 7509, Reims, France
| | | | | | | | - Tristan Gloede
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut, USA
| | | | - Jacques Massol
- Aixial Consulting, Boulogne Billancourt, France
- Remede Consulting Group, Paris, France
| | | | | | - Hervé Bachelez
- Service de Dermatologie, Assistance Publique-Hôpitaux de Paris Hôpital Saint-Louis, and INSERM Unité 1163, Imagine Institute of Genetic Diseases, Université Paris Cité, Paris, France
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Chu I, Miller R, Mathews I, Vala A, Sept L, O’Hara R, Rehkopf DH. FAIR enough: Building an academic data ecosystem to make real-world data available for translational research. J Clin Transl Sci 2024; 8:e92. [PMID: 38836249 PMCID: PMC11148826 DOI: 10.1017/cts.2024.530] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/08/2024] [Accepted: 04/23/2024] [Indexed: 06/06/2024] Open
Abstract
The Stanford Population Health Sciences Data Ecosystem was created to facilitate the use of large datasets containing health records from hundreds of millions of individuals. This necessitated technical solutions optimized for an academic medical center to manage and share high-risk data at scale. Through collaboration with internal and external partners, we have built a Data Ecosystem to host, curate, and share data with hundreds of users in a secure and compliant manner. This platform has enabled us to host unique data assets and serve the needs of researchers across Stanford University, and the technology and approach were designed to be replicable and portable to other institutions. We have found, however, that though these technological advances are necessary, they are not sufficient. Challenges around making data Findable, Accessible, Interoperable, and Reusable remain. Our experience has demonstrated that there is a high demand for access to real-world data, and that if the appropriate tools and structures are in place, translational research can be advanced considerably. Together, technological solutions, management structures, and education to support researcher, data science, and community collaborations offer more impactful processes over the long-term for supporting translational research with real-world data.
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Affiliation(s)
- Isabella Chu
- The Stanford Center for Population Health Sciences, Stanford School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Rebecca Miller
- The Stanford Center for Population Health Sciences, Stanford School of Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Ayin Vala
- The Stanford Center for Population Health Sciences, Stanford School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Lesley Sept
- The Stanford Center for Population Health Sciences, Stanford School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Ruth O’Hara
- Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Veterans Administration Palo Alto Health Care System, Sierra Pacific Mental Illness, Research, Education, and Clinical Center, Palo Alto, CA, USA
| | - David H. Rehkopf
- The Stanford Center for Population Health Sciences, Stanford School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Department of Medicine, Division of Primary Care and Population Health, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Department of Health Policy, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Department of Sociology, Stanford University, Stanford, CA, USA
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Martin GL, Petri C, Rozenberg J, Simon N, Hajage D, Kirchgesner J, Tubach F, Létinier L, Dechartres A. A methodological review of the high-dimensional propensity score in comparative-effectiveness and safety-of-interventions research finds incomplete reporting relative to algorithm development and robustness. J Clin Epidemiol 2024; 169:111305. [PMID: 38417583 DOI: 10.1016/j.jclinepi.2024.111305] [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] [Received: 12/04/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVES The use of secondary databases has become popular for evaluating the effectiveness and safety of interventions in real-life settings. However, the absence of important confounders in these databases is challenging. To address this issue, the high-dimensional propensity score (hdPS) algorithm was developed in 2009. This algorithm uses proxy variables for mitigating confounding by combining information available across several healthcare dimensions. This study assessed the methodology and reporting of the hdPS in comparative effectiveness and safety research. STUDY DESIGN AND SETTING In this methodological review, we searched PubMed and Google Scholar from July 2009 to May 2022 for studies that used the hdPS for evaluating the effectiveness or safety of healthcare interventions. Two reviewers independently extracted study characteristics and assessed how the hdPS was applied and reported. Risk of bias was evaluated with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. RESULTS In total, 136 studies met the inclusion criteria; the median publication year was 2018 (Q1-Q3 2016-2020). The studies included 192 datasets, mostly North American databases (n = 132, 69%). The hdPS was used in primary analysis in 120 studies (88%). Dimensions were defined in 101 studies (74%), with a median of 5 (Q1-Q3 4-6) dimensions included. A median of 500 (Q1-Q3 200-500) empirically identified covariates were selected. Regarding hdPS reporting, only 11 studies (8%) reported all recommended items. Most studies (n = 81, 60%) had a moderate overall risk of bias. CONCLUSION There is room for improvement in the reporting of hdPS studies, especially regarding the transparency of methodological choices that underpin the construction of the hdPS.
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Affiliation(s)
- Guillaume Louis Martin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France; Synapse Medicine, Bordeaux, France.
| | - Camille Petri
- UKRI Centre for Doctoral Training in AI for Healthcare, Imperial College London, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Noémie Simon
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | - Julien Kirchgesner
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Département de Gastroentérologie et Nutrition, Paris, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | | | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
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Htoo PT, Glynn RJ, Wang S, Paik JM, Schneeweiss S, Walker AM, Patorno E. Stratified analysis in comparative effectiveness studies that emulate randomized trials. Pharmacoepidemiol Drug Saf 2024; 33:e5716. [PMID: 37876341 DOI: 10.1002/pds.5716] [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: 03/29/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE For observational cohort studies that employ matching by propensity scores (PS), preliminary stratification by consequential predictors of outcome better emulates stratified randomization and potentially reduces variance and bias through relaxed dependence on modeling assumptions. We assessed the impact of pre-stratification in two real-life examples. For both, prior evidence from placebo-controlled randomized clinical trials (RCTs) suggested small or no risk reduction, but observational analysis suggested protection, presumably the result of confounding bias. STUDY DESIGN AND SETTING The study populations consisted of Medicare beneficiaries (2014-18) with type 2 diabetes initiating either (i) empagliflozin versus dipeptidyl peptidase-4 inhibitors (DPP-4i) or (ii) empagliflozin versus glucagon-like peptide-1 receptor agonists (GLP-1RA). The outcome was myocardial infarction or stroke. We estimated hazard ratios (HR) and rate differences (RD) after controlling for 143 pre-exposure covariates via 1:1 PS matching after (1) PS estimation in the total cohort (total-cohort PS-matching) and (2) PS estimation separately by baseline cardiovascular disease (stratified PS matching). RESULTS Stratified PS matching resulted in HRs that exceeded those from total-cohort PS-matching by 13% and 9%, respectively, for the comparisons of empagliflozin to DPP-4i and GLP-1RA. Against both comparators, HRs and RDs after stratified PS matching were closer to the null, with slightly higher variances (2%-3%) than those after total-cohort PS matching. CONCLUSION Stratified PS matching produced effect estimates closer to the expected trial findings than total-cohort PS matching. The price paid in increased variance was minimal.
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Affiliation(s)
- Phyo T Htoo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shirley Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander M Walker
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Gibbs LR, Ali AK, Albright DG, Rubinstein ER, Klesh R, Zimmerman R, Garry EM. Characteristics and outcomes of pregnancies in the Maternal Outcomes Masterset real-world database. Pharmacoepidemiol Drug Saf 2024; 33:e5697. [PMID: 37743799 DOI: 10.1002/pds.5697] [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] [Received: 02/17/2023] [Revised: 06/30/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE Describe patient characteristics and pregnancy outcomes among all pregnant patients, and additionally describe infant outcomes among the subset with linked infants in the Maternal Outcomes Masterset (MOM). METHODS We used closed claims within the MOM data to identify publicly and privately insured patients at the first record of pregnancy January 1, 2018-December 1, 2021, with ≥180 days baseline enrollment. We described characteristics during baseline and follow-up (until an observed pregnancy endpoint, disenrollment, or 42-week maximum). We described maternal and infant characteristics overall and by infant linkage and contextualized them within national statistics. RESULTS Among the 1 438 861 pregnant patients meeting the study criteria, the most common pregnancy endpoint recorded was live birth (42%) followed by spontaneous abortion (14%). Among 602 721 patients with a live birth, 99% had a week-specific gestational age recorded and 35% had at least one linked infant. Patients with infant linkage and sufficient follow-up (N = 155 621) had similar baseline comorbidities, pregnancy complications, and gestational age at delivery as those without any linkage. However, more patients with linkage had commercial coverage (70% vs. 31%), and were therefore older (50% vs. 31% aged ≥30 years) and more likely to have an unknown race (57% vs. 34%). CONCLUSIONS In this large sample of pregnant patients, maternal and infant characteristics generally align with national statistics, providing confidence in the use of this data source for pregnancy research. Further, confirmation that the subset of patients with infant linkage is similar to the overall pregnancy cohort provides assurance that this subset can be considered representative.
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Affiliation(s)
- Liza R Gibbs
- Scientific Research and Strategy, Aetion, Inc., New York, New York, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Ayad K Ali
- Scientific Research and Strategy, Aetion, Inc., New York, New York, USA
| | - Dawn G Albright
- Scientific Data Insights, Aetion, Inc., New York, New York, USA
| | | | - Reyna Klesh
- Data Product & Innovation, HealthVerity, Inc., Philadelphia, Pennsylvania, USA
| | - Ruth Zimmerman
- Data Insights & Analytics, HealthVerity, Inc., Philadelphia, Pennsylvania, USA
| | - Elizabeth M Garry
- Scientific Research and Strategy, Aetion, Inc., New York, New York, USA
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Ma HK, Wang YM, Guo MP, Li CF, Li R, Gao R. Effectiveness of Acupoint Application in Patients with Pharyngeal Pain: Evidence from CHUNBO, A Prospective Real-World Study. Chin J Integr Med 2024; 30:18-24. [PMID: 37340204 DOI: 10.1007/s11655-023-3699-8] [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] [Accepted: 03/01/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE To assess the outcomes after acupoint application in patients with pharyngeal pain in a real-world settings, and analyze the characteristics of effective population and prescription characteristics of acupoint application. METHODS Based on CHUNBO platform, patients with pharyngeal pain who were candidates for acupoint application on the basis of physician-evaluation, were enrolled in a nationwide, prospective, 69-week multicenter observational study from August 2020 to February 2022. Propensity score matching (PSM) was used to match the confounding factors and the association rules were used to analyze the characteristics of effective population and prescription characteristics of acupoint application. Outcome assessments included the disappearance rate of pharyngeal pain (within 3, 7, and 14 days), disappearance time of pharyngeal pain, as well as adverse events. RESULTS Of 7,699 enrolled participants, 6,693 (86.9%) received acupoint application and 1,450 (21.7%) with non-acupoint application. After PSM, there were 1,004 patients each in the application group (AG) and non-application group (NAG). The disappearance rate of pharyngeal pain in the AG at 3, 7, and 14 days were all higher than those in the NAG (P<0.05). The disappearance time of pharyngeal pain in the AG were shorter than that in the NAG (logrank P<0.001, hazard ratio=1.51, 95% confidence interval: 1.41-1.63). The median age of effective cases was 4 years, mainly 3-6 years old (40.21%). The disappearance rate of pharyngeal pain in the application group with tonsil diseases was 2.19 times higher than that in the NAG (P<0.05). The commonly used acupoints for the effective cases were Tiantu (RN 22), Shenque (RN 8) and Dazhui (DU 14). The commonly used herbs for the effective cases were Natrii sulfas, Radix et Rhizoma Rhei, and Herba Ephedrae. Among them, Natrii sulfas was applied to RN 8 most frequently (support 84.39%). A total of 1,324 (17.2%) patients experienced AEs, and mainly occurred in the AG, with significant difference in the incidence of AEs between goups (P<0.05). All AEs reported were the first grade, and the average regression days of AEs was 2.8 days. CONCLUSIONS Acupoint application in patients with pharyngeal pain resulted in improved effective rate and shortened duration, especially children aged 3-6 years old, and those with tonsil diseases. Acupoint of RN 22, RN 8 and DU 14, Natrii sulfas, Radix et Rhizoma Rhei, and Herba Ephedrae were the most commonly used herbs in the treatment of pharyngeal pain.
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Affiliation(s)
- Hang-Kun Ma
- Emergency Department, Xiyuan Hospital Affiliated to China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Yi-Ming Wang
- National Medical Products Administration for Laboratory of Clinical Research and Evaluation of Traditional Chinese Medicine, Beijing, 100091, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, 100091, China
| | - Man-Ping Guo
- National Medical Products Administration for Laboratory of Clinical Research and Evaluation of Traditional Chinese Medicine, Beijing, 100091, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, 100091, China
- Postdoctoral Workstation of Yabao Pharmaceutical Group Co., Ltd., Yuncheng, Shanxi Province, 044602, China
| | - Chen-Fei Li
- National Medical Products Administration for Laboratory of Clinical Research and Evaluation of Traditional Chinese Medicine, Beijing, 100091, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, 100091, China
| | - Rui Li
- National Medical Products Administration for Laboratory of Clinical Research and Evaluation of Traditional Chinese Medicine, Beijing, 100091, China
- Postdoctoral Workstation of Yabao Pharmaceutical Group Co., Ltd., Yuncheng, Shanxi Province, 044602, China
| | - Rui Gao
- National Medical Products Administration for Laboratory of Clinical Research and Evaluation of Traditional Chinese Medicine, Beijing, 100091, China.
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, 100091, China.
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White R. Building trust in real world evidence (RWE): moving transparency in RWE towards the randomized controlled trial standard. Curr Med Res Opin 2023; 39:1737-1741. [PMID: 37787381 DOI: 10.1080/03007995.2023.2263353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
Abstract
The increasing use of RWE in regulatory and reimbursement decision-making indicates the significant progress that has been made in building trust in RWE through greater transparency. This review of the published literature and key online sources was conducted to provide an update on progress towards greater transparency in RWE, based on four key barriers to trust identified in a 2016 paper and applying learnings from transparency initiatives established for RCTs, such as the US FDA Amendments Act (FDAAA) 2007 Final Rule. Multiple initiatives from the US FDA, EMA and organizations such as the ISPOR-ISPE Joint Task Force have yielded new guidance documents and tools that enable greater transparency in RWE study methodology (STaRT-RWE and HARPER templates), data source selection and quality (SPIFD2 framework, REQueST tool), strategy (the Center for Open Science RWE Study Registry), and will therefore improve transparency in RWE study reporting. Programs such as the REPEAT Initiative and RWE DUPLICATE are investigating reproducibility of RWE studies and improving understanding of the circumstances when valid inference on treatment effects can be obtained from RWE studies. Further work is needed to embed and to implement the new tools and guidance that are available, and thus raise standards for RWE transparency towards the levels expected for RCTs.
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Affiliation(s)
- Richard White
- Oxford PharmaGenesis, Oxford, UK
- Green Templeton College, University of Oxford, Oxford, UK
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11
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Htoo P, Paik J, Alt E, Kim D, Wexler D, Kim S, Patorno E. Risk of Severe Hypoglycemia With Newer Second-line Glucose-lowering Medications in Older Adults With Type 2 Diabetes Stratified by Known Indicators of Hypoglycemia Risk. J Gerontol A Biol Sci Med Sci 2023; 78:2426-2434. [PMID: 36866496 PMCID: PMC10692415 DOI: 10.1093/gerona/glad075] [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: 09/07/2022] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Severe hypoglycemia is associated with adverse clinical outcomes. We evaluated the risk of severe hypoglycemia in older adults initiating newer glucose-lowering medications overall and across strata of known indicators of high hypoglycemia risk. METHODS We conducted a comparative-effectiveness cohort study of older adults aged >65 years with type 2 diabetes initiating sodium-glucose cotransporter 2 inhibitors (SGLT2i) versus dipeptidyl peptidase-4 inhibitors (DPP-4i) or SGLT2i versus glucagon-like peptide-1 receptor agonists (GLP-1RA) using Medicare claims (3/2013-12/2018) and Medicare-linked-electronic health records. We identified severe hypoglycemia requiring emergency or inpatient visits using validated algorithms. After 1:1 propensity score matching, we estimated hazard ratios (HR) and rate differences (RD) per 1,000 person-years. Analyses were stratified by baseline insulin, sulfonylurea, cardiovascular disease (CVD), chronic kidney disease (CKD), and frailty. RESULTS Over a median follow-up of 7 (interquartile range: 4-16) months, SGLT2i was associated with a reduced risk of hypoglycemia versus DPP-4i (HR 0.75 [0.68, 0.83]; RD -3.21 [-4.29, -2.12]), and versus GLP-1RA (HR 0.90 [0.82, 0.98]; RD -1.33 [-2.44, -0.23]). RD for SGLT2i versus DPP-4i was larger in patients using baseline insulin than in those not, although HRs were similar. In patients using baseline sulfonylurea, the risk of hypoglycemia was lower in SGLT2i versus DPP-4i (HR 0.57 [0.49, 0.65], RD -6.80 [-8.43, -5.16]), while the association was near-null in those without baseline sulfonylurea. Results stratified by baseline CVD, CKD and frailty were similar to the overall cohort findings. Findings for the GLP-1RA comparison were similar. CONCLUSIONS SGLT2i was associated with a lower hypoglycemia risk versus incretin-based medications, with larger associations in patients using baseline insulin or sulfonylurea.
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Affiliation(s)
- Phyo T Htoo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Ethan Alt
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dae Hyun Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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12
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Acha V, Barefoot B, Juarez Garcia A, Lehner V, Monno R, Sandler S, Spooner A, Verpillat P. Principles for Good Practice in the Conduct of Non-interventional Studies: The View of Industry Researchers. Ther Innov Regul Sci 2023; 57:1199-1208. [PMID: 37460826 PMCID: PMC10579109 DOI: 10.1007/s43441-023-00544-y] [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] [Received: 08/05/2022] [Accepted: 06/02/2023] [Indexed: 10/17/2023]
Abstract
This reflection paper presents a consolidated view of EFPIA on the need for principles for good practice in the generation and use of non-interventional studies (NIS), including overarching principles such as the registration of hypothesis evaluating treatment effect (HETE) studies. We first define NIS and the important adjacencies to clinical trials and relationship with real-world evidence (RWE). We then outline the principles for good practice with respect to appropriate research design, study protocol, fit-for-purpose variables and data quality, analytical methods, bias reduction, transparency in conduct and use, privacy management and ethics review. We conclude with recommendations for action for the research community to promote trust and credibility in the use of NIS.
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13
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Tazare J, Gibbons DC, Bokern M, Williamson EJ, Gillespie IA, Cunnington M, Logie J, Douglas IJ. Prevalent new user designs: A literature review of current implementation practice. Pharmacoepidemiol Drug Saf 2023; 32:1252-1260. [PMID: 37309989 DOI: 10.1002/pds.5656] [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: 12/14/2022] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023]
Abstract
PURPOSE Prevalent new user (PNU) designs extend the active comparator new user design by allowing for the inclusion of initiators of the study drug who were previously on a comparator treatment. We performed a literature review summarising current practice. METHODS PubMed was searched for studies applying the PNU design since its proposal in 2017. The review focused on three components. First, we extracted information on the overall study design, including the database used. We summarised information on implementation of the PNU design, including key decisions relating to exposure set definition and estimation of time-conditional propensity scores. Finally, we reviewed the analysis strategy of the matched cohort. RESULTS Nineteen studies met the criteria for inclusion. Most studies (73%) implemented the PNU design in electronic health record or registry databases, with the remaining using insurance claims databases. Of 15 studies including a class of prevalent users, 40% deviated from the original exposure set definition proposals in favour of a more complex definition. Four studies did not include prevalent new users but used other aspects of the PNU framework. Several studies lacked details on exposure set definition (n = 2), time-conditional propensity score model (n = 2) or integration of complex analytical techniques, such as the high-dimensional propensity score algorithm (n = 3). CONCLUSION PNU designs have been applied in a range of therapeutic and disease areas. However, to encourage more widespread use of this design and help shape best practice, there is a need for improved accessibility, specifically through the provision of analytical code alongside guidance to support implementation and transparent reporting.
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Affiliation(s)
- John Tazare
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Marleen Bokern
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth J Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Health Data Research United Kingdom (HDR-UK), London, UK
| | | | | | | | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Health Data Research United Kingdom (HDR-UK), London, UK
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14
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Ben-Joseph RH, Saad R, Black J, Dabrowski EC, Taylor B, Gallucci S, Somers VK. Cardiovascular Burden of Narcolepsy Disease (CV-BOND): a real-world evidence study. Sleep 2023; 46:zsad161. [PMID: 37305967 PMCID: PMC10566243 DOI: 10.1093/sleep/zsad161] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 05/25/2023] [Indexed: 06/13/2023] Open
Abstract
STUDY OBJECTIVES Narcolepsy is associated with cardiovascular risk factors; however, the risk of new-onset cardiovascular events in this population is unknown. This real-world study evaluated the excess risk of new-onset cardiovascular events in U.S. adults with narcolepsy. METHODS A retrospective cohort study using IBM MarketScan administrative claims data (2014-2019) was conducted. A narcolepsy cohort, comprising adults (≥18 years) with at least two outpatient claims containing a narcolepsy diagnosis, of which at least one was non-diagnostic, was matched to a non-narcolepsy control cohort (1:3) based on cohort entry date, age, sex, geographic region, and insurance type. The relative risk of new-onset cardiovascular events was estimated using a multivariable Cox proportional hazards model to compute adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS The narcolepsy and matched non-narcolepsy control cohorts included 12 816 and 38 441 individuals, respectively. At baseline, cohort demographics were generally similar; however, patients with narcolepsy had more comorbidities. In adjusted analyses, the risk of new-onset cardiovascular events was higher in the narcolepsy cohort compared with the control cohort: any stroke (HR [95% CI], 1.71 [1.24, 2.34]); heart failure (1.35 [1.03, 1.76]); ischemic stroke (1.67 [1.19, 2.34]); major adverse cardiac event (1.45 [1.20, 1.74]); grouped instances of stroke, atrial fibrillation, or edema (1.48 [1.25, 1.74]); and cardiovascular disease (1.30 [1.08, 1.56]). CONCLUSION Individuals with narcolepsy are at increased risk of new-onset cardiovascular events compared with individuals without narcolepsy. Physicians should consider cardiovascular risk in patients with narcolepsy when weighing treatment options.
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Affiliation(s)
| | - Ragy Saad
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | - Jed Black
- Jazz Pharmaceuticals, Palo Alto, CA, USA
- Stanford University Center for Sleep Sciences and Medicine, Palo Alto, CA, USA
| | | | | | | | - Virend K Somers
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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15
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Shin H, Wang SV, Kim DH, Alt E, Mahesri M, Bessette LG, Schneeweiss S, Najafzadeh M. Predicting Treatment Effects of a New-to-Market Drug in Clinical Practice Based on Phase III Randomized Trial Results. Clin Pharmacol Ther 2023; 114:853-861. [PMID: 37365904 PMCID: PMC10851912 DOI: 10.1002/cpt.2983] [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: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
Trial results may not be generalizable to target populations treated in clinical practice with different distributions of baseline characteristics that modify the treatment effect. We used outcome models developed with trial data to predict treatment effects in Medicare populations. We used data from the Randomized Evaluation of Long-Term Anticoagulation Therapy trial (RE-LY), which investigated the effect of dabigatran vs. warfarin on stroke or systemic embolism (stroke/SE) among patients with atrial fibrillation. We developed outcome models by fitting proportional hazards models in trial data. Target populations were trial-eligible Medicare beneficiaries who initiated dabigatran or warfarin in 2010-2011 ("early") and 2010-2017 ("extended"). We predicted 2-year risk ratios (RRs) and risk differences (RDs) for stroke/SE, major bleeding, and all-cause death in the Medicare populations using the observed baseline characteristics. The trial and early target populations had similar mean (SD) CHADS2 scores (2.15 (SD 1.13) vs. 2.15 (SD 0.91)) but different mean ages (71 vs. 79 years). Compared with RE-LY, the early Medicare population had similar predicted benefit of dabigatran vs. warfarin for stroke/SE (trial RR = 0.63, 95% confidence interval (CI) = 0.50 to 0.76 and RD = -1.37%, -1.96% to -0.77%, Medicare RR = 0.73, 0.65 to 0.82 and RD = -0.92%, -1.26% to -0.59%) and risks for major bleeding and all-cause death. The time-extended target population showed similar results. Outcome model-based prediction facilitates estimating the average treatment effects of a drug in different target populations when treatment and outcome data are unreliable or unavailable. The predicted effects may inform payers' coverage decisions for patients, especially shortly after a drug's launch when observational data are scarce.
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Affiliation(s)
- HoJin Shin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Shirley V. Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Department of Medicine, Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ethan Alt
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Lily G. Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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16
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van Wijk RC, Mockeliunas L, van den Hoogen G, Upton CM, Diacon AH, Simonsson USH. Reproducibility in pharmacometrics applied in a phase III trial of BCG-vaccination for COVID-19. Sci Rep 2023; 13:16292. [PMID: 37770596 PMCID: PMC10539503 DOI: 10.1038/s41598-023-43412-3] [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: 06/15/2022] [Accepted: 09/23/2023] [Indexed: 09/30/2023] Open
Abstract
Large clinical trials often generate complex and large datasets which need to be presented frequently throughout the trial for interim analysis or to inform a data safety monitory board (DSMB). In addition, reliable and traceability are required to ensure reproducibility in pharmacometric data analysis. A reproducible pharmacometric analysis workflow was developed during a large clinical trial involving 1000 participants over one year testing Bacillus Calmette-Guérin (BCG) (re)vaccination in coronavirus disease 2019 (COVID-19) morbidity and mortality in frontline health care workers. The workflow was designed to review data iteratively during the trial, compile frequent reports to the DSMB, and prepare for rapid pharmacometric analysis. Clinical trial datasets (n = 41) were transferred iteratively throughout the trial for review. An RMarkdown based pharmacometric processing script was written to automatically generate reports for evaluation by the DSMB. Reports were compiled, reviewed, and sent to the DSMB on average three days after the data cut-off, reflecting the trial progress in real-time. The script was also utilized to prepare for the trial pharmacometric analyses. The same source data was used to create analysis datasets in NONMEM format and to support model script development. The primary endpoint analysis was completed three days after data lock and unblinding, and the secondary endpoint analyses two weeks later. The constructive collaboration between clinical, data management, and pharmacometric teams enabled this efficient, timely, and reproducible pharmacometrics workflow.
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Affiliation(s)
- Rob C van Wijk
- Department of Pharmaceutical Biosciences, Uppsala University, Box 591, 75124, Uppsala, Sweden
| | - Laurynas Mockeliunas
- Department of Pharmaceutical Biosciences, Uppsala University, Box 591, 75124, Uppsala, Sweden
| | | | | | | | - Ulrika S H Simonsson
- Department of Pharmaceutical Biosciences, Uppsala University, Box 591, 75124, Uppsala, Sweden.
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17
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Roy S, Ye T, Ertefaie A, Vo TT, Flory J, Hennessy S, Small D. Group sequential testing under instrumented difference-in-differences approach. Stat Med 2023; 42:3838-3859. [PMID: 37345519 DOI: 10.1002/sim.9836] [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: 11/03/2022] [Revised: 04/15/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023]
Abstract
Unmeasured confounding is a major obstacle to reliable causal inference based on observational studies. Instrumented difference-in-differences (iDiD), a novel idea connecting instrumental variable and standard DiD, ameliorates the above issue by explicitly leveraging exogenous randomness in an exposure trend. In this article, we utilize the above idea of iDiD, and propose a novel group sequential testing method that provides valid inference even in the presence of unmeasured confounders. At each time point, we estimate the average or conditional average treatment effect under iDiD setting using the data accumulated up to that time point, and test the significance of the treatment effect. We derive the joint distribution of the test statistics under the null using the asymptotic properties of M-estimation, and the group sequential boundaries are obtained using theα $$ \alpha $$ -spending functions. The performance of our proposed approach is evaluated on both synthetic data and Clinformatics Data Mart Database (OptumInsight, Eden Prairie, MN) to examine the association between rofecoxib and acute myocardial infarction, and our method detects significant adverse effect of rofecoxib much earlier than the time when it was finally withdrawn from the market.
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Affiliation(s)
- Samrat Roy
- Department of Statistics and Data Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ting Ye
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Ashkan Ertefaie
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Tat-Thang Vo
- Department of Statistics and Data Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James Flory
- Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sean Hennessy
- Division of Epidemiology, DBEI, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dylan Small
- Department of Statistics and Data Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Ostropolets A, Albogami Y, Conover M, Banda JM, Baumgartner WA, Blacketer C, Desai P, DuVall SL, Fortin S, Gilbert JP, Golozar A, Ide J, Kanter AS, Kern DM, Kim C, Lai LYH, Li C, Liu F, Lynch KE, Minty E, Neves MI, Ng DQ, Obene T, Pera V, Pratt N, Rao G, Rappoport N, Reinecke I, Saroufim P, Shoaibi A, Simon K, Suchard MA, Swerdel JN, Voss EA, Weaver J, Zhang L, Hripcsak G, Ryan PB. Reproducible variability: assessing investigator discordance across 9 research teams attempting to reproduce the same observational study. J Am Med Inform Assoc 2023; 30:859-868. [PMID: 36826399 PMCID: PMC10114120 DOI: 10.1093/jamia/ocad009] [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: 11/25/2022] [Revised: 01/04/2023] [Accepted: 01/23/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE Observational studies can impact patient care but must be robust and reproducible. Nonreproducibility is primarily caused by unclear reporting of design choices and analytic procedures. This study aimed to: (1) assess how the study logic described in an observational study could be interpreted by independent researchers and (2) quantify the impact of interpretations' variability on patient characteristics. MATERIALS AND METHODS Nine teams of highly qualified researchers reproduced a cohort from a study by Albogami et al. The teams were provided the clinical codes and access to the tools to create cohort definitions such that the only variable part was their logic choices. We executed teams' cohort definitions against the database and compared the number of subjects, patient overlap, and patient characteristics. RESULTS On average, the teams' interpretations fully aligned with the master implementation in 4 out of 10 inclusion criteria with at least 4 deviations per team. Cohorts' size varied from one-third of the master cohort size to 10 times the cohort size (2159-63 619 subjects compared to 6196 subjects). Median agreement was 9.4% (interquartile range 15.3-16.2%). The teams' cohorts significantly differed from the master implementation by at least 2 baseline characteristics, and most of the teams differed by at least 5. CONCLUSIONS Independent research teams attempting to reproduce the study based on its free-text description alone produce different implementations that vary in the population size and composition. Sharing analytical code supported by a common data model and open-source tools allows reproducing a study unambiguously thereby preserving initial design choices.
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Affiliation(s)
- Anna Ostropolets
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
| | - Yasser Albogami
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mitchell Conover
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - Juan M Banda
- Department of Computer Science, Georgia State University, Atlanta, Georgia, USA
| | - William A Baumgartner
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Clair Blacketer
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - Priyamvada Desai
- Research IT, Technology and Digital Solutions, Stanford Medicine, Stanford, California, USA
| | - Scott L DuVall
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Stephen Fortin
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - James P Gilbert
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | | | - Joshua Ide
- Johnson & Johnson, Titusville, New Jersey, USA
| | - Andrew S Kanter
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
| | - David M Kern
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - Chungsoo Kim
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, South Korea
| | - Lana Y H Lai
- Department of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Chenyu Li
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Feifan Liu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Kristine E Lynch
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Evan Minty
- O’Brien Institute for Public Health, Faculty of Medicine, University of Calgary, Calgary, Canada
| | | | - Ding Quan Ng
- Department of Pharmaceutical Sciences, School of Pharmacy & Pharmaceutical Sciences, University of California, Irvine, California, USA
| | - Tontel Obene
- Mississippi Urban Research Center, Jackson State University, Jackson, Mississippi, USA
| | - Victor Pera
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, Australia
| | - Gowtham Rao
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - Nadav Rappoport
- Department of Software and Information Systems Engineering, Ben-Gurion University of the Negev, Israel
| | - Ines Reinecke
- Institute for Medical Informatics and Biometry, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Paola Saroufim
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Azza Shoaibi
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - Katherine Simon
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marc A Suchard
- Department of Biostatistics, University of California, Los Angeles, California, USA
- Department of Human Genetics, University of California, Los Angeles, California, USA
| | - Joel N Swerdel
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - Erica A Voss
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - James Weaver
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
| | - Linying Zhang
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
- Medical Informatics Services, New York-Presbyterian Hospital, New York, New York, USA
| | - Patrick B Ryan
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
- Observational Health Data Analytics, Janssen Research & Development, Titusville, New Jersey, USA
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19
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Hydroxychloroquine lowers Alzheimer's disease and related dementias risk and rescues molecular phenotypes related to Alzheimer's disease. Mol Psychiatry 2023; 28:1312-1326. [PMID: 36577843 PMCID: PMC10005941 DOI: 10.1038/s41380-022-01912-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/29/2022]
Abstract
We recently nominated cytokine signaling through the Janus-kinase-signal transducer and activator of transcription (JAK/STAT) pathway as a potential AD drug target. As hydroxychloroquine (HCQ) has recently been shown to inactivate STAT3, we hypothesized that it may impact AD pathogenesis and risk. Among 109,124 rheumatoid arthritis patients from routine clinical care, HCQ initiation was associated with a lower risk of incident AD compared to methotrexate initiation across 4 alternative analyses schemes addressing specific types of biases including informative censoring, reverse causality, and outcome misclassification (hazard ratio [95% confidence interval] of 0.92 [0.83-1.00], 0.87 [0.81-0.93], 0.84 [0.76-0.93], and 0.87 [0.75-1.01]). We additionally show that HCQ exerts dose-dependent effects on late long-term potentiation (LTP) and rescues impaired hippocampal synaptic plasticity prior to significant accumulation of amyloid plaques and neurodegeneration in APP/PS1 mice. Additionally, HCQ treatment enhances microglial clearance of Aβ1-42, lowers neuroinflammation, and reduces tau phosphorylation in cell culture-based phenotypic assays. Finally, we show that HCQ inactivates STAT3 in microglia, neurons, and astrocytes suggesting a plausible mechanism associated with its observed effects on AD pathogenesis. HCQ, a relatively safe and inexpensive drug in current use may be a promising disease-modifying AD treatment. This hypothesis merits testing through adequately powered clinical trials in at-risk individuals during preclinical stages of disease progression.
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Li Y, Tian Y, Pei S, Xie B, Xu X, Wang B. Worldwide Trends in Registering Real-World Studies at ClinicalTrials.gov: A Cross-Sectional Analysis. Int J Gen Med 2023; 16:1123-1136. [PMID: 37007912 PMCID: PMC10065426 DOI: 10.2147/ijgm.s402478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Objective The purpose of this study was to characterize real-world studies (RWSs) registered at ClinicalTrials.gov to help investigators better conduct relevant research in clinical practice. Methods A retrospective analysis of 944 studies was performed on February 28, 2023. Results A total of 944 studies were included. The included studies involved a total of 48 countries. China was the leading country in terms of the total number of registered studies (37.9%, 358), followed by the United States (19.7%, 186). Regarding intervention type, 42.4% (400) of the studies involved drugs, and only 9.1% (86) of the studies involved devices. Only 8.5% (80) of the studies mentioned both the detailed study design type and data source in the "Brief Summary". A total of 49.4% (466) of studies had a sample size of 500 participants and above. Overall, 63% (595) of the studies were single-center studies. A total of 213 conditions were covered in the included studies. One-third of the studies (32.7%, 309) involved neoplasms (or tumors). China and the United States were very different regarding the study of different conditions. Conclusion Although the pandemic has provided new opportunities for RWSs, the rigor of scientific research still needs to be emphasized. Special attention needs to be given to the correct and comprehensive description of the study design in the Brief Summary of registered studies, thereby promoting communication and understanding. In addition, deficiencies in ClinicalTrials.gov registration data remain prominent.
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Affiliation(s)
- Yuanxiao Li
- Department of Pediatric Gastroenterology, Lanzhou University Second Hospital, Lanzhou, People’s Republic of China
| | - Ying Tian
- Department of Clinical Medicine, Lanzhou University Second Hospital, Lanzhou, People’s Republic of China
| | - Shufen Pei
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, People’s Republic of China
| | - Baoyuan Xie
- Department of Clinical Medicine, Lanzhou University Second Hospital, Lanzhou, People’s Republic of China
| | - Xiaonan Xu
- Department of Pediatric Gastroenterology, Lanzhou University Second Hospital, Lanzhou, People’s Republic of China
| | - Bin Wang
- Department of Infectious Diseases, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Correspondence: Bin Wang, 88 Jie Fang Lu, Shangcheng District, Hangzhou, Zhejiang, 310009, People’s Republic of China, Email
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21
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Schneeweiss MC, Savage TJ, Wyss R, Jin Y, Schoder K, Merola JF, Sidbury R, Oduol T, Schneeweiss S, Glynn RJ. Risk of Infection in Children With Psoriasis Receiving Treatment With Ustekinumab, Etanercept, or Methotrexate Before and After Labeling Expansion. JAMA Dermatol 2023; 159:289-298. [PMID: 36753234 PMCID: PMC9909570 DOI: 10.1001/jamadermatol.2022.6325] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/11/2022] [Indexed: 02/09/2023]
Abstract
Importance Psoriasis in children is increasingly treated with systemic medications, yet their risk of serious infection is not well characterized in clinical practice. Pediatric clinical trials for these medications were often small and placebo controlled. Objective To estimate the 6-month rate of infections among children with psoriasis who started treatment with ustekinumab, etanercept, or methotrexate. Design, Setting, and Participants This cohort study used insurance claims data from clinical practices across the US on children aged 17 years or younger with psoriasis who were receiving treatment with a topical medication for psoriasis and started new treatment with ustekinumab, etanercept, or methotrexate. The analysis was stratified by the time before pediatric labeling (2009-2015) and after pediatric approval (2016-2021). Patient follow-up started 1 day after initiating treatment and ended at 6 months. Exposures New treatment with ustekinumab, etanercept, and methotrexate. Main Outcomes and Measures During follow-up, the frequency of inpatient serious infections and outpatient infections requiring treatment was compared. Event rates and rate ratios were estimated after propensity score decile stratification. Results After exclusions, we identified 2338 patients (1368 girls [57.8%]) who initiated new treatment with a targeted immunomodulating agent. In all, 379 patients started treatment with ustekinumab, 779 patients started treatment with etanercept, and 1180 patients started treatment with methotrexate from 2009 through 2021. The propensity score-adjusted incidence rate of serious infection was 18.4 per 1000 person-years (3 events) for ustekinumab users, 25.6 per 1000 person-years (9 events) for etanercept users, and 14.9 per 1000 person-years (8 events) for methotrexate users. The adjusted rate of outpatient infections was 254.9 per 1000 person-years (39 events) for ustekinumab users, 435.7 per 1000 person-years (139 events) for etanercept users, and 433.6 per 1000 person-years (209 events) for methotrexate users. The adjusted rate ratio of outpatient infections was 0.58 (95% CI, 0.41-0.83) for ustekinumab vs etanercept, 0.66 (95% CI, 0.48-0.91) for ustekinumab vs methotrexate, and 0.95 (95% CI, 0.75-1.21) for etanercept vs methotrexate. Rate ratios were similar during the off-label use era and after pediatric labeling. Conclusions and Relevance Among children with psoriasis who started treatment with immunomodulating agents, serious infections were infrequent. This cohort study suggests that there was no increase in the risk of outpatient infections for children who started treatment with ustekinumab compared with etanercept or methotrexate.
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Affiliation(s)
- Maria C. Schneeweiss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy J. Savage
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Disease, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Wyss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yinzhu Jin
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katharina Schoder
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph F. Merola
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert Sidbury
- Division of Dermatology, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
| | - Theresa Oduol
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert J. Glynn
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Lin KJ, Singer DE, Bykov K, Bessette LG, Mastrorilli JM, Cervone A, Kim DH. Comparative Effectiveness and Safety of Oral Anticoagulants by Dementia Status in Older Patients With Atrial Fibrillation. JAMA Netw Open 2023; 6:e234086. [PMID: 36976562 PMCID: PMC10051113 DOI: 10.1001/jamanetworkopen.2023.4086] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/04/2023] [Indexed: 03/29/2023] Open
Abstract
Importance The development of an optimal stroke prevention strategy, including the use of oral anticoagulant (OAC) therapy, is particularly important for patients with atrial fibrillation (AF) who are living with dementia, a condition that increases the risk of adverse outcomes. However, data on the role of dementia in the safety and effectiveness of OACs are limited. Objective To assess the comparative safety and effectiveness of specific OACs by dementia status among older patients with AF. Design, Setting, and Participants This retrospective comparative effectiveness study used 1:1 propensity score matching among 1 160 462 patients 65 years or older with AF. Data were obtained from the Optum Clinformatics Data Mart (January 1, 2013, to June 30, 2021), IBM MarketScan Research Database (January 1, 2013, to December 31, 2020), and Medicare claims databases maintained by the Centers for Medicare & Medicaid Services (inpatient, outpatient, and pharmacy; January 1, 2013, to December 31, 2017). Data analysis was performed from September 1, 2021, to May 24, 2022. Exposures Apixaban, dabigatran, rivaroxaban, or warfarin. Main Outcomes and Measures Composite end point of ischemic stroke or major bleeding events over the 6-month period after OAC initiation, pooled across databases using random-effects meta-analyses. Results Among 1 160 462 patients with AF, the mean (SD) age was 77.4 (7.2) years; 50.2% were male, 80.5% were White, and 7.9% had dementia. Three comparative new-user cohorts were established: warfarin vs apixaban (501 990 patients; mean [SD] age, 78.1 [7.4] years; 50.2% female), dabigatran vs apixaban (126 718 patients; mean [SD] age, 76.5 [7.1] years; 52.0% male), and rivaroxaban vs apixaban (531 754 patients; mean [SD] age, 76.9 [7.2] years; 50.2% male). Among patients with dementia, compared with apixaban users, a higher rate of the composite end point was observed in warfarin users (95.7 events per 1000 person-years [PYs] vs 64.2 events per 1000 PYs; adjusted hazard ratio [aHR], 1.5; 95% CI, 1.3-1.7), dabigatran users (84.5 events per 1000 PYs vs 54.9 events per 1000 PYs; aHR, 1.5; 95% CI, 1.2-2.0), and rivaroxaban users (87.4 events per 1000 PYs vs 68.5 events per 1000 PYs; aHR, 1.3; 95% CI, 1.1-1.5). In all 3 comparisons, the magnitude of the benefits associated with apixaban was similar regardless of dementia diagnosis on the HR scale but differed substantially on the rate difference (RD) scale. The adjusted RD of the composite outcome per 1000 PYs for warfarin vs apixaban users was 29.8 (95% CI, 18.4-41.1) events in patients with dementia vs 16.0 (95% CI, 13.6-18.4) events in patients without dementia. The corresponding adjusted RD estimates of the composite outcome were 29.6 (95% CI, 11.6-47.6) events per 1000 PYs in patients with dementia vs 5.8 (95% CI, 1.1-10.4) events per 1000 PYs in patients without dementia for dabigatran vs apixaban users and 20.5 (95% CI, 9.9-31.1) events per 1000 PYs in patients with dementia vs 15.9 (95% CI, 11.4-20.3) events per 1000 PYs in patients without dementia for rivaroxaban vs apixaban users. The pattern was more distinct for major bleeding than for ischemic stroke. Conclusions and Relevance In this comparative effectiveness study, apixaban was associated with lower rates of major bleeding and ischemic stroke compared with other OACs. The increased absolute risks associated with other OACs compared with apixaban were greater among patients with dementia than those without dementia, particularly for major bleeding. These findings support the use of apixaban for anticoagulation therapy in patients living with dementia who have AF.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Daniel E. Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lily G. Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Julianna M. Mastrorilli
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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23
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Simon TG, Schneeweiss S, Singer DE, Sreedhara SK, Lin KJ. Prescribing Trends of Oral Anticoagulants in US Patients With Cirrhosis and Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2023; 12:e026863. [PMID: 36625307 PMCID: PMC9973619 DOI: 10.1161/jaha.122.026863] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/30/2022] [Indexed: 01/11/2023]
Abstract
Background Many patients with cirrhosis have concurrent nonvalvular atrial fibrillation (NVAF). Data are lacking regarding recent oral anticoagulant (OAC) usage trends among US patients with cirrhosis and NVAF. Methods and Results Using MarketScan claims data (2012-2019), we identified patients with cirrhosis and NVAF eligible for OACs (CHA2DS2-VASc score ≥2 [men] or ≥3 [women]). We calculated the yearly proportion of patients prescribed a direct OAC (DOAC), warfarin, or no OAC. We stratified by high-risk features (decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease, or end-stage renal disease). Among 32 487 patients (mean age=71.6 years, 38.5% women, 15.1% with decompensated cirrhosis, mean CHA2DS2-VASc=4.2), 44.6% used OACs within 180 days of NVAF diagnosis, including DOACs (20.2%) or warfarin (24.4%). Compared with OAC nonusers, OAC users were less likely to have decompensated cirrhosis (18.6% versus 10.7%), thrombocytopenia (19.5% versus 12.5%), or chronic kidney disease/end-stage renal disease (15.5% versus 14.0%). Between 2012 and 2019, warfarin use decreased by 21.0% (32.0% to 11.0%), whereas DOAC use increased by 30.6% (7.4% to 38.0%), and among all DOACs between 2012 and 2019, apixaban was the most commonly prescribed (46.1%). Warfarin use decreased and DOAC use increased in all subgroups, including in compensated and decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease/end-stage renal disease, and across CHA2DS2-VASc categories. Among OAC users (2012-2019), DOAC use increased by 58.9% (18.7% to 77.6%). Among DOAC users, the greatest proportional increase was with apixaban (61.2%; P<0.001). Conclusions Among US patients with cirrhosis and NVAF, DOAC use has increased substantially and surpassed warfarin, including in decompensated cirrhosis. Nevertheless, >55% of patients remain untreated, underscoring the need for clearer treatment guidance.
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Affiliation(s)
- Tracey G. Simon
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
- Division of Gastroenterology and HepatologyDepartment of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Daniel E. Singer
- Division of General Internal MedicineDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMA
| | - Sushama Kattinakere Sreedhara
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
- Division of General Internal MedicineDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMA
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24
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Desai RJ, Glynn RJ, Everett BM, Schneeweiss S, Wexler DJ, Bessette LG, Déruaz-Luyet A, Vedin O, Brodovicz K, Patorno E. Comparative effectiveness of Empagliflozin in reducing the burden of recurrent cardiovascular hospitalizations among older adults with diabetes in routine clinical care. Am Heart J 2022; 254:203-215. [PMID: 36150454 DOI: 10.1016/j.ahj.2022.09.008] [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] [Received: 09/24/2021] [Revised: 07/21/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The effect of sodium glucose cotransporter 2 inhibitors (SGLT2i) on the total (first and recurrent) burden of cardiovascular (CV) hospitalizations, including hospitalization for heart failure, myocardial infarction, and stroke, is poorly understood. OBJECTIVE To assess the effect of empagliflozin, an SGLT2i, on total CV hospitalizations among older adults with T2D. METHODS Using data from Medicare fee-for-service (08/2014-09/2017), we identified 1:1 propensity score-matched cohorts of patients with T2D initiating empagliflozin versus sitagliptin or empagliflozin versus glucagon-like peptide-1 receptor agonists (GLP-1RA), balancing >140 baseline covariates. We compared the risk of first and recurrent hospitalizations with any CV condition as the primary discharge diagnosis (ICD-9: 390-459; ICD-10: I00-I99), hospitalizations for heart failure (HHF), and myocardial infarctions (MI) or stroke. We estimated treatment effects based on the Ghosh-Lin semiparametric model for recurrent events as primary and joint frailty model as secondary analysis. RESULTS We included 11,429 matched-pairs of empagliflozin and sitagliptin initiators and 17,502 matched-pairs of empagliflozin and GLP1-RA initiators with an average age of 72 years. Empagliflozin was associated with a reduced risk of total CV hospitalizations (0.80 [0.69-0.93] vs sitagliptin; 0.88 [0.77-1.00] vs GLP-1RA) and total HHF (0.70 [0.51-0.98] vs sitagliptin; 0.76 [0.56-1.03] vs GLP1-RA) over a mean follow up of 6.3 months. No differences between treatments were observed for MI or stroke. Results were consistent for joint frailty models. CONCLUSION Empagliflozin, compared to sitagliptin or to a lesser extent GLP1-RA, was associated with a reduction in the burden of total CV hospitalizations and HHF in older patients with T2D.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.
| | - Robert J Glynn
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Brendan M Everett
- Divisions of Cardiovascular and Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, MA
| | - Lily G Bessette
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Anouk Déruaz-Luyet
- Boehringer Ingelheim, Ingelheim (Germany), Stockholm, (Sweden), and Ridgefield, CT
| | - Ola Vedin
- Boehringer Ingelheim, Ingelheim (Germany), Stockholm, (Sweden), and Ridgefield, CT
| | - Kimberly Brodovicz
- Boehringer Ingelheim, Ingelheim (Germany), Stockholm, (Sweden), and Ridgefield, CT
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
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Cardiovascular and Mortality Risk with Intravitreal Vascular Endothelial Growth Factor Inhibitors in Patients with Diabetic Retinopathy. Ophthalmol Retina 2022; 6:1145-1153. [PMID: 35777664 DOI: 10.1016/j.oret.2022.06.010] [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: 02/14/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the cardiovascular (CV) safety associated with intravitreal anti-VEGF injections (IAVIs) in patients with diabetic retinopathy (DR). DESIGN Population-based cohort study using Medicare and 2 commercial insurance claims databases in the United States from January 2009 to December 2017. SUBJECTS Patients with DR aged ≥ 18 years in whom treatment with either IVAIs or laser procedure or intravitreal steroid injections was initiated. METHODS We estimated the propensity score (PS) using multivariable logistic regression models, including 85 baseline covariates and PS-matched patients in a 1:1 ratio. We estimated the pooled hazard ratios (HRs) and 95% confidence intervals (CIs). Subgroup analyses based on prior history of CV events were also conducted. MAIN OUTCOME MEASURES A composite CV outcome of myocardial infarction (MI) or stroke, its individual components, and all-cause mortality in 180 and 365 days after treatment initiation. RESULTS We identified 61 508 PS-matched patients in a 1:1 ratio in whom either IVAIs or laser or steroid treatment was initiated. Compared with laser or steroid treatment, IAVIs were not associated with an increased risk of the composite CV outcome (HR, 0.95; 95% CI, 0.83-1.09), MI (HR, 0.93; 95% CI, 0.76-1.13), or stroke (HR, 0.98; 95% CI, 0.80-1.19) or the risk of all-cause mortality (HR, 1.25; 95% CI, 0.97-1.62) at 180 days of follow-up. At 365 days, the risk of the composite CV outcome, stroke, and MI remained similar between the 2 groups, although the risk of all-cause mortality was increased with IAVIs (HR, 1.35; 95% CI, 1.14-1.60). The subgroup analysis showed that the risk of all-cause mortality was increased in patients with a prior history of CV events. CONCLUSIONS Among > 60 000 patients with DR, those who received IAVIs had a risk of CV events similar to those who received laser or steroid treatment. However, the risk of all-cause mortality was higher in patients who received IAVIs for DR.
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Incidence of Bacterial and Nonbacterial Conjunctivitis in Patients With Atopic Dermatitis Treated With Dupilumab: A US Multidatabase Cohort Study. Dermatitis 2022; 33:S73-S82. [PMID: 35170520 PMCID: PMC9376195 DOI: 10.1097/der.0000000000000843] [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: 11/26/2022]
Abstract
BACKGROUND Dupilumab-associated conjunctivitis in patients with atopic dermatitis (AD) is not fully characterized. OBJECTIVE The aim of the study was to characterize the incidence of bacterial and nonbacterial conjunctivitis among patients with AD who initiated dupilumab. METHODS Pooling longitudinal claims data from 2 US databases, we identified AD patients who newly filled either dupilumab or methotrexate, mycophenolate or cyclosporine, between March 2017 and January 2020. Outcomes were conjunctivitis and its subtypes, bacterial, allergic, and keratoconjunctivitis. Patient follow-up lasted 6 months and 1:1 propensity score (PS) matching-controlled confounding. RESULTS Within 6 months of treatment initiation, the incidence of conjunctivitis was 6.6% in 3744 dupilumab initiators; bacterial conjunctivitis, 1.5%; allergic conjunctivitis, 2.2%; keratoconjunctivitis, 0.8%; and conjunctivitis requiring ophthalmic medication, 2.7%. After PS matching, dupilumab doubled the risk of conjunctivitis compared with methotrexate (relative risk [RR] 2.12; 1.56-2.91), mycophenolate (RR = 2.43; 1.32-4.47), or cyclosporine (RR = 1.83; 1.05-3.20). Risk of bacterial conjunctivitis was 1.6- to 4.0-fold increased with wide confidence intervals, and allergic conjunctivitis was increased 2.7- to 7-fold. There was no increased risk of keratoconjunctivitis. Patients with comorbid asthma had a further increased risk of conjunctivitis. CONCLUSIONS One in 15 patients treated with dupilumab developed conjunctivitis driven by bacterial and allergic conjunctivitis and not keratoconjunctivitis. This risk was further increased with comorbid asthma.
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Wang SV, Sreedhara SK, Bessette LG, Schneeweiss S. Understanding variation in the results of real-world evidence studies that seem to address the same question. J Clin Epidemiol 2022; 151:161-170. [PMID: 36075314 DOI: 10.1016/j.jclinepi.2022.08.012] [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: 02/07/2022] [Revised: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Multiple database studies on the same question, conducted by different investigators using different approaches or different data sources, can be considered sensitivity analyses for the same causal treatment effect question. We evaluated the contribution of alternative study design parameters and analysis choices to variation in estimates of the risk of major bleeding with dabigatran compared with warfarin. STUDY DESIGN AND SETTING We followed a 7-step process: (1) identify published studies asking the same question, (2) independently reproduce selected studies in the same data sources as the original authors, (3) contact original authors, (4) evaluate validity, (5) document critical study parameter specifications, (6) implement a designed matrix of variations in study parameters based on the original studies, and (7) evaluate contributors to variation in results. RESULTS Most variation remained unexplained (60-88%). Of the explained variation, two-thirds were related to data and population differences, and one-third were related to the use of alternative study design and analysis parameters. Among these, the most prominent were differences in outcome algorithms and criteria used to define follow-up. CONCLUSION When making policy decisions based on database study findings, it is important to evaluate the validity, consistency, and robustness of results to alternative design and analysis decisions.
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Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, 1630 Tremont St Suite 303, Boston, MA 02120, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital; Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | | | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital; Department of Medicine, Harvard Medical School, Boston, MA, USA
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28
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Desai RJ, Mahesri M, Lee SB, Varma VR, Loeffler T, Schilcher I, Gerhard T, Segal JB, Ritchey ME, Horton DB, Kim SC, Schneeweiss S, Thambisetty M. No association between initiation of phosphodiesterase-5 inhibitors and risk of incident Alzheimer's disease and related dementia: results from the Drug Repurposing for Effective Alzheimer's Medicines study. Brain Commun 2022; 4:fcac247. [PMID: 36330433 PMCID: PMC9598543 DOI: 10.1093/braincomms/fcac247] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 07/11/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
We evaluated the hypothesis that phosphodiesterase-5 inhibitors, including sildenafil and tadalafil, may be associated with reduced incidence of Alzheimer's disease and related dementia using a patient-level cohort study of Medicare claims and cell culture-based phenotypic assays. We compared incidence of Alzheimer's disease and related dementia after phosphodiesterase-5 inhibitor initiation versus endothelin receptor antagonist initiation among patients with pulmonary hypertension after controlling for 76 confounding variables through propensity score matching. Across four separate analytic approaches designed to address specific types of biases including informative censoring, reverse causality, and outcome misclassification, we observed no evidence for a reduced risk of Alzheimer's disease and related dementia with phosphodiesterase-5 inhibitors;hazard ratio (95% confidence interval): 0.99 (0.69-1.43), 1.00 (0.71-1.42), 0.67 (0.43-1.06), and 1.15 (0.57-2.34). We also did not observe evidence that sildenafil ameliorated molecular abnormalities relevant to Alzheimer's disease in most cell culture-based phenotypic assays. These results do not provide support to the hypothesis that phosphodiesterase-5 inhibitors are promising repurposing candidates for Alzheimer's disease and related dementia.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA 02115, USA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA 02115, USA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA 02115, USA
| | - Vijay R Varma
- Clinical & Translational Neuroscience Section, Laboratory of Behavioral Neuroscience, National Institute on Aging, Baltimore, MD 21224, USA
| | - Tina Loeffler
- QPS Austria GmbH, Parkring 12, 8074 Grambach, Austria
| | | | - Tobias Gerhard
- Rutgers Center for Pharmacoepidemiology and Treatment Science, New Brunswick, NJ 08901, USA
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, USA
| | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Mary E Ritchey
- Rutgers Center for Pharmacoepidemiology and Treatment Science, New Brunswick, NJ 08901, USA
| | - Daniel B Horton
- Rutgers Center for Pharmacoepidemiology and Treatment Science, New Brunswick, NJ 08901, USA
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ 08901, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA 02115, USA
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA 02115, USA
| | - Madhav Thambisetty
- Clinical & Translational Neuroscience Section, Laboratory of Behavioral Neuroscience, National Institute on Aging, Baltimore, MD 21224, USA
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Vititoe SE, Easthausen IJ, Lasky T, Chakravarty A, Bradley MC, Roe LM, Gatto NM, Weckstein AR, Garry EM. Describing characteristics and treatment patterns of patients hospitalized with COVID-19 by race and ethnicity in a national RWD during the early months of the pandemic. PLoS One 2022; 17:e0267815. [PMID: 36155644 PMCID: PMC9512177 DOI: 10.1371/journal.pone.0267815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/17/2022] [Indexed: 11/18/2022] Open
Abstract
Objective
To describe differences by race and ethnicity in treatment patterns among hospitalized COVID-19 patients in the US from March-August 2020.
Methods
Among patients in de-identified Optum electronic health record data hospitalized with COVID-19 (March-August 2020), we estimated odds ratios of receiving COVID-19 treatments of interest (azithromycin, dexamethasone, hydroxychloroquine, remdesivir, and other steroids) at hospital admission, by race and ethnicity, after adjusting for key covariates of interest.
Results
After adjusting for key covariates, Black/African American patients were less likely to receive dexamethasone (adj. OR [95% CI]: 0.83 [0.71, 0.96]) and more likely to receive other steroids corticosteroids (adj. OR [95% CI]: 2.13 [1.90, 2.39]), relative to White patients. Hispanic/Latino patients were less likely to receive dexamethasone than Not Hispanic/Latino patients (adj. OR [95% CI]: 0.69 [0.58, 0.82]).
Conclusions
Our findings suggest that COVID-19 treatments patients received in Optum varied by race and ethnicity after adjustment for other possible explanatory factors. In the face of rapidly evolving treatment landscapes, policies are needed to ensure equitable access to novel and repurposed therapeutics to avoid disparities in care by race and ethnicity.
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Affiliation(s)
- Sarah E. Vititoe
- Scientific Research & Strategy, Aetion, Inc., New York, New York, United States of America
| | - Imaani J. Easthausen
- Scientific Research & Strategy, Aetion, Inc., New York, New York, United States of America
| | - Tamar Lasky
- Office of the Commissioner, U.S. Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Aloka Chakravarty
- Office of the Commissioner, U.S. Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Marie C. Bradley
- Division of Epidemiology, Office of Surveillance and Epidemiology, Center For Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Laura M. Roe
- Division of Epidemiology, Office of Surveillance and Epidemiology, Center For Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Nicolle M. Gatto
- Scientific Research & Strategy, Aetion, Inc., New York, New York, United States of America
- Columbia Mailman School of Public Health, New York, New York, United States of America
- Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
| | - Andrew R. Weckstein
- Scientific Research & Strategy, Aetion, Inc., New York, New York, United States of America
| | - Elizabeth M. Garry
- Scientific Research & Strategy, Aetion, Inc., New York, New York, United States of America
- * E-mail:
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30
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Kirchgesner J, Desai RJ, Schneeweiss MC, Beaugerie L, Schneeweiss S, Kim SC. Decreased risk of treatment failure with vedolizumab and thiopurines combined compared with vedolizumab monotherapy in Crohn's disease. Gut 2022; 71:1781-1789. [PMID: 35387877 DOI: 10.1136/gutjnl-2022-327002] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/27/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE While infliximab combined to thiopurines is more effective than infliximab monotherapy in patients with Crohn's disease (CD) and UC, the impact of adding thiopurines to vedolizumab remains controversial. We emulated two target trials comparing the effectiveness of combination therapy versus vedolizumab monotherapy in CD and UC. DESIGN Based on two US and the French nationwide healthcare databases, patients with CD and UC who initiated vedolizumab were identified. The study methodology, including confounding adjustment and outcome definitions, were previously validated in successful emulations of the SONIC and SUCCESS trials. Risk ratios for treatment failure based on hospitalisation or surgery related to disease activity, treatment switch, or prolonged corticosteroids use, were estimated after 1:1 propensity score (PS) matching. RESULTS Among a total of 10 299 vedolizumab users, 804 CD and 1088 UC pairs of combination therapy versus vedolizumab monotherapy users were PS matched. Treatment failure occurred at week 26 in 236 (29.3%) and 376 (34.3%) patients with CD and at week 16 in 236 (21.7%) and 263 (24.2%) patients with UC initiating combination therapy and vedolizumab monotherapy, respectively. The risk of treatment failure was decreased with combination therapy compared with vedolizumab monotherapy in CD (RR 0.85, 95% CI: 0.74 to 0.98) and to a lesser extent in UC (RR 0.90, 95% CI: 0.77 to 1.05). Findings were consistent across databases. CONCLUSION Using validated methodologies, combination therapy with vedolizumab and thiopurines was associated with lower treatment failure compared with vedolizumab monotherapy in CD but not UC across the USA and France.
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Affiliation(s)
- Julien Kirchgesner
- Gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris, France .,Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France.,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Maria C Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Laurent Beaugerie
- Gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris, France.,Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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31
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Wang SV, Sreedhara SK, Schneeweiss S. Reproducibility of real-world evidence studies using clinical practice data to inform regulatory and coverage decisions. Nat Commun 2022; 13:5126. [PMID: 36045130 PMCID: PMC9430007 DOI: 10.1038/s41467-022-32310-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 07/26/2022] [Indexed: 11/26/2022] Open
Abstract
Studies that generate real-world evidence on the effects of medical products through analysis of digital data collected in clinical practice provide key insights for regulators, payers, and other healthcare decision-makers. Ensuring reproducibility of such findings is fundamental to effective evidence-based decision-making. We reproduce results for 150 studies published in peer-reviewed journals using the same healthcare databases as original investigators and evaluate the completeness of reporting for 250. Original and reproduction effect sizes were positively correlated (Pearson’s correlation = 0.85), a strong relationship with some room for improvement. The median and interquartile range for the relative magnitude of effect (e.g., hazard ratiooriginal/hazard ratioreproduction) is 1.0 [0.9, 1.1], range [0.3, 2.1]. While the majority of results are closely reproduced, a subset are not. The latter can be explained by incomplete reporting and updated data. Greater methodological transparency aligned with new guidance may further improve reproducibility and validity assessment, thus facilitating evidence-based decision-making. Study registration number: EUPAS19636. Analyses of real-world evidence from digital clinical practice data provide important insights for healthcare decision makers. Here, authors test reproducibility of 150 peer-reviewed studies, reporting strong reproducibility, which could be further improved through more complete reporting in future original studies
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Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | | | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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Merola D, Schneeweiss S, Sreedhara SK, Zabotka LE, Quinto K, Concato J, Wang SV. Real-World Evidence Prediction of a Phase IV Oncology Trial: Comparative Degarelix vs Leuprolide Safety. JNCI Cancer Spectr 2022; 6:pkac049. [PMID: 35947646 PMCID: PMC9403105 DOI: 10.1093/jncics/pkac049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Medical and regulatory communities are increasingly interested in the utility of real-world evidence (RWE) for answering questions pertaining to drug safety and effectiveness but concerns about validity remain. A principled approach to conducting RWE studies may alleviate concerns and increase confidence in findings. This study sought to predict the findings from the PRONOUNCE trial using a principled approach to generating RWE. METHODS This propensity-score (PS) matched observational cohort study utilized 3 claims databases to compare the occurrence of major adverse cardiovascular events (MACE) among initiators of degarelix vs. leuprolide. Patients were included if they had history of prostate cancer and atherosclerotic cardiovascular disease. Subjects were excluded if they didn't have continuous database enrollment in the year prior to treatment initiation, were exposed to androgen deprivation therapy or experienced an acute cardiovascular event within 30 days prior to treatment initiation, or had a history or risk factors of QT prolongation. RESULTS There were 12,448 leuprolide and 1,969 degarelix study-eligible patients before matching, with 1,887 in each arm after PS-matching. The results for MACE comparing degarelix to leuprolide in the observational analysis (hazard ratio= 1.35; 95% confidence interval = 0.94-1.93) was consistent with the subsequently released PRONOUNCE result (hazard ratio = 1.28; 95% confidence interval = 0.59-2.79). CONCLUSIONS This study successfully predicted the result of a comparative cardiovascular safety trial in the oncology setting. Although the findings are encouraging, limitations of measuring cancer stage and tumor progression are representative of challenges in attempting to generalize whether claims-based RWE can be used as actionable evidence.
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Affiliation(s)
- David Merola
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sushama K Sreedhara
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Luke E Zabotka
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth Quinto
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - John Concato
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Shin H, Schneeweiss S, Glynn RJ, Patorno E. Cardiovascular Outcomes in Patients Initiating First-Line Treatment of Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors Versus Metformin : A Cohort Study. Ann Intern Med 2022; 175:927-937. [PMID: 35605236 DOI: 10.7326/m21-4012] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Evidence on the risk for cardiovascular events associated with use of first-line sodium-glucose cotransporter-2 inhibitors (SGLT-2i) compared with metformin is limited. OBJECTIVE To assess cardiovascular outcomes among adults with type 2 diabetes (T2D) who initiated first-line treatment with SGLT-2i versus metformin. DESIGN Population-based cohort study. SETTING Claims data from 2 large U.S. commercial and Medicare databases (April 2013 to March 2020). PARTICIPANTS Patients with T2D aged 18 years and older (>65 years in Medicare) initiating treatment with SGLT-2i or metformin during April 2013 to March 2020, without any use of antidiabetic medications before cohort entry, were identified. After 1:2 propensity score matching in each database, pooled hazard ratios (HRs) and 95% CIs were reported. INTERVENTION First-line SGLT-2i (canagliflozin, empagliflozin, or dapagliflozin) or metformin. MEASUREMENTS Primary outcomes were a composite of hospitalization for myocardial infarction (MI), hospitalization for ischemic or hemorrhagic stroke or all-cause mortality (MI/stroke/mortality), and a composite of hospitalization for heart failure (HHF) or all-cause mortality (HHF/mortality). Safety outcomes including genital infections were assessed. RESULTS Among 8613 first-line SGLT-2i initiators matched to 17 226 metformin initiators, SGLT-2i initiators had a similar risk for MI/stroke/mortality (HR, 0.96; 95% CI, 0.77 to 1.19) and a lower risk for HHF/mortality (HR, 0.80; CI, 0.66 to 0.97) during a mean follow-up of 12 months. Initiators receiving SGLT-2i showed a lower risk for HHF (HR, 0.78; CI, 0.63 to 0.97), a numerically lower risk for MI (HR, 0.70; CI, 0.48 to 1.00), and similar risk for stroke, mortality, and MI/stroke/HHF/mortality compared with metformin. Initiators receiving SGLT-2i had a higher risk for genital infections (HR, 2.19; CI, 1.91 to 2.51) and otherwise similar safety as those receiving metformin. LIMITATION Treatment selection was not randomized. CONCLUSION As first-line T2D treatment, initiators receiving SGLT-2i showed a similar risk for MI/stroke/mortality, lower risk for HHF/mortality and HHF, and a similar safety profile except for an increased risk for genital infections compared with those receiving metformin. PRIMARY FUNDING SOURCE Brigham and Women's Hospital and Harvard Medical School.
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Affiliation(s)
- HoJin Shin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (H.S., R.J.G., E.P.)
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (S.S.)
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (H.S., R.J.G., E.P.)
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (H.S., R.J.G., E.P.)
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Schneeweiss MC, Kirchgesner J, Wyss R, Jin Y, York C, Merola JF, Mostaghimi A, Silverberg JI, Schneeweiss S, Glynn RJ. Occurrence of inflammatory bowel disease in patients with chronic inflammatory skin diseases: a cohort study. Br J Dermatol 2022; 187:692-703. [PMID: 35718888 DOI: 10.1111/bjd.21704] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/11/2022] [Accepted: 06/11/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies linked various chronic inflammatory skin diseases (CISDs) with inflammatory bowel disease (IBD) in a range of data sources with mixed conclusions. OBJECTIVE We compared the incidence of IBD-ulcerative colitis (UC) and Crohn's disease (CD)- in patients with a CISD versus similar persons without a CISD. METHODS In this cohort study using nationwide, longitudinal, commercial insurance claims data from the US, we identified adults and children who were seen by a dermatologist between 2004-2020, and diagnosed with either psoriasis, atopic dermatitis, alopecia areata, vitiligo, or hidradenitis suppurativa. Comparator patients were identified through risk-set sampling; they were eligible if they were seen by a dermatologist at least twice and not diagnosed with a CISD. Patient follow-up lasted until either IBD diagnosis, death, disenrollment, or end of data stream, whichever came first. IBD events, ulcerative colitis (UC) or Crohn's (CD), were identified via validated algorithms-hospitalization or diagnosis with endoscopic confirmation. Incidence rates were computed before and after adjustment via propensity-score (PS) decile stratification to account for IBD risk factors. Hazard ratios (HR) and 95% confidence intervals were estimated to compare the incidence of IBD in CISD versus non-CISD. RESULTS We identified patients with atopic dermatitis (n=123,614), psoriasis (n=83,049), alopecia areata (n=18,135), vitiligo (n=9,003) or hidradenitis suppurativa (n=6,806), and comparator patients without a CISD (n=2,376,120). During a median follow-up time of 718 days, and after applying PS adjustment for IBD risk factors, we observed increased risk of both UC (HRUC =2.30; 1.61-3.28) and CD (HRCD =2.70; 1.69-4.32) in patients with hidradenitis suppurativa, an increased risk of CD (HRCD =1.23; 1.03-1.46) but not UC (HRUC =1.01; 0.89-1.14) in psoriasis, and no increased risk of IBD in atopic dermatitis (HRUC =1.02; 0.92-1.12, HRCD =1.08; 0.94-1.23), alopecia areata (HRUC =1.18; 0.89-1.56, HRCD =1.26; 0.86-1.86) or vitiligo (HRUC =1.14; 0.77-1.68, HRCD =1.45; 0.87-2.41). CONCLUSIONS IBD was increased in patients with hidradenitis suppurativa. Crohn's disease alone was increased in patients with psoriasis. Neither ulcerative colitis nor Crohn's disease was increased in patients with atopic dermatitis, alopecia areata or vitiligo.
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Affiliation(s)
- Maria C Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Julien Kirchgesner
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard Wyss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cassandra York
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joseph F Merola
- Harvard Medical School, Boston, MA, USA.,Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA.,Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Arash Mostaghimi
- Harvard Medical School, Boston, MA, USA.,Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan I Silverberg
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Simon TG, Patorno E, Schneeweiss S. Glucagon-Like Peptide-1 Receptor Agonists and Hepatic Decompensation Events in Patients With Cirrhosis and Diabetes. Clin Gastroenterol Hepatol 2022; 20:1382-1393.e19. [PMID: 34256144 PMCID: PMC8743301 DOI: 10.1016/j.cgh.2021.07.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The study sought to compare the effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1RAs) with dipeptidyl peptidase-4 (DPP-4) inhibitors, sulfonylureas, or sodium-glucose cotransporter-2 (SGLT-2) inhibitors in reducing decompensation events, among patients with cirrhosis and type 2 diabetes. METHODS This population-based, retrospective cohort study included patients with type 2 diabetes and cirrhosis, in a commercial healthcare database (IBM MarketScan). We constructed 3 pairwise, 1:1 propensity score (PS)-matched cohorts of adults initiating GLP-1RAs or a comparator medication (ie, DPP-4 inhibitors [2006-2020], sulfonylurea [2005-2020], or SGLT-2 inhibitors [2013-2020]). Patients were followed in an as-treated approach for decompensation events (ie, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy, or esophageal variceal hemorrhage). Within each PS-matched cohort, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs), controlling for >90 baseline characteristics. RESULTS Over 132 days of median follow-up (interquartile range, 73-290 days), PS-matched rates of any decompensation were significantly lower among GLP-1RA initiators, versus DPP-4 inhibitor initiators (105.2 vs 144.0 per 1000 person-years [PY]; HR, 0.68; 95% CI, 0.53-0.88; n = 1431 pairs), and versus sulfonylureas (97.3 vs 144.0 per 1000 PY; HR, 0.64; 95% CI, 0.48-0.84; n = 1246 pairs). Similar, inverse associations were found for individual decompensation events, including ascites, spontaneous bacterial peritonitis, or hepatorenal syndrome (HR, 0.66; 95% CI, 0.45-0.97; and HR, 0.66; 95% CI, 0.46-0.94, respectively); esophageal variceal hemorrhage (HR, 0.62 [95% CI, 0.41-0.92; and HR, 0.59; 95% CI, 0.37-0.92, respectively); and hepatic encephalopathy (HR, 0.76; 95% CI, 0.55-1.06; and HR, 0.60; 95% CI, 0.39-0.92, respectively). Results persisted in subgroups of patients with and without previously decompensated cirrhosis. In contrast, decompensation rates were similar when GLP-1RAs and SGLT-2 inhibitors were directly compared (103.5 vs 112.8 per 1000 PY; HR, 0.89; 95% CI, 0.62-1.28). CONCLUSIONS Among cirrhotic patients with type 2 diabetes, we find high rates of decompensation, consistent with previous reports; these rates were substantially lower among GLP-1RA initiators compared with DPP-4 inhibitors or sulfonylureas.
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Affiliation(s)
- Tracey G. Simon
- Division of Gastroenterology and Hepatology, 55 Fruit Street Wang 5, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Clinical and Translational Epidemiology Unit (CTEU), Massachusetts General Hospital, Boston, MA, USA,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Suite 3030, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Suite 3030, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Suite 3030, Boston, MA, USA
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Garry EM, Weckstein AR, Quinto K, Bradley MC, Lasky T, Chakravarty A, Leonard S, Vititoe SE, Easthausen IJ, Rassen JA, Gatto NM. Categorization of
COVID
‐19 severity to determine mortality risk. Pharmacoepidemiol Drug Saf 2022; 31:721-728. [PMID: 35373865 PMCID: PMC9088650 DOI: 10.1002/pds.5436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/24/2022] [Accepted: 03/30/2022] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Kenneth Quinto
- Office of Medical Policy Center for Drug Evaluation and Research, U.S. Food and Drug Administration Silver Spring MD USA
| | - Marie C. Bradley
- Division of Epidemiology, Office of Surveillance and Epidemiology Center for Drug Evaluation and Research, U.S. Food and Drug Administration Silver Spring MD USA
| | - Tamar Lasky
- Office of the Commissioner U.S. Food and Drug Administration Silver Spring MD USA
| | - Aloka Chakravarty
- Office of the Commissioner U.S. Food and Drug Administration Silver Spring MD USA
| | - Sandy Leonard
- Partnerships and RWD HealthVerity Philadelphia PA USA
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Ayele HT, Douros A, Filion KB. 5-Alpha Reductase Inhibitors and the Risk of Anemia among Men with Benign Prostatic Hyperplasia: A Population-based Cohort Study. Br J Clin Pharmacol 2022; 88:3771-3781. [PMID: 35301747 DOI: 10.1111/bcp.15317] [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: 07/19/2021] [Revised: 01/29/2022] [Accepted: 02/26/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND 5-alpha reductase inhibitors (5αRIs) are effective for the treatment of benign prostatic hyperplasia (BPH). However, 5αRIs could lower levels of hemoglobin, increasing the risk of anemia. OBJECTIVE To compare the rate of anemia between new users of 5αRIs and α-blockers in the United Kingdom (UK). METHODS We conducted a matched, active comparator, new-user cohort study using the Clinical Practice Research Datalink. The study population consisted of men aged 40+ years with incident BPH who initiated 5αRIs between 1998 and 2019 and were matched 1:1 on propensity score to new users of α-blockers. Anemia was defined by a measured hemoglobin < 130 g/l. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for anemia. RESULTS Our study cohort included 9,429 new users of 5αRIs and 9,429 matched new users of α-blockers. Their median durations of follow-up were 136 days (interquartile range [IQR]: 54-336 days) and 77 days (IQR: 58-236), respectively. A total of 2,865 5αRIs users and 2,407 α-blocker users developed incident anemia, representing rates of 37.3 (95% CI: 33.6-41.3) and 42.0 (95% CI: 38.1-46.2) per 100 person-years, respectively. The use of 5αRIs was not associated with an increased risk of anemia compared to the use of α-blockers (HR: 0.95, 95% CI: 0.90-1.00). Similarly, we did not observe an increased risk of mild, moderate, or severe anemia. CONCLUSION The use of 5αRIs was not associated with an increased risk of anemia compared to the use of α-blockers among men with BPH.
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Affiliation(s)
- Henok Tadesse Ayele
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University Montréal, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Canada
| | - Antonios Douros
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University Montréal, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Canada.,Department of Medicine, McGill University, Montréal, Canada.,Institute of Clinical Pharmacology and Toxicology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University Montréal, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Canada.,Department of Medicine, McGill University, Montréal, Canada
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Patorno E, Pawar A, Wexler DJ, Glynn RJ, Bessette LG, Paik JM, Najafzadeh M, Brodovicz KG, Déruaz-Luyet A, Schneeweiss S. Effectiveness and safety of empagliflozin in routine care patients: Results from the EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) study. Diabetes Obes Metab 2022; 24:442-454. [PMID: 34729891 PMCID: PMC8939295 DOI: 10.1111/dom.14593] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 01/10/2023]
Abstract
AIM To investigate effectiveness and safety outcomes among patients with type 2 diabetes (T2D) initiating empagliflozin versus dipeptidyl peptidase-4 (DPP-4) inhibitor treatment across the broad spectrum of cardiovascular risk. METHODS In a population-based cohort study we identified 39 072 pairs of 1:1 propensity score-matched adult patients with T2D initiating empagliflozin or DPP-4 inhibitors, using data from 2 US commercial insurance databases and Medicare between August 2014 and September 2017. The primary outcomes were a composite of myocardial infarction (MI)/stroke, and hospitalization for heart failure (HHF). Safety outcomes were bone fractures, lower-limb amputations (LLAs), diabetic ketoacidosis (DKA), and acute kidney injury (AKI). We estimated pooled hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for more than 140 baseline covariates. RESULTS Study participants had a mean age of 60 years and only 28% had established cardiovascular disease. Compared to DPP-4 inhibitors, empagliflozin was associated with similar risk of MI/stroke (HR 0.99 [95% CI 0.81-1.21]), and lower risk of HHF (HR 0.48 [95% CI 0.35-0.67] and 0.63 [95% CI 0.54-0.74], based on a primary and any heart failure discharge diagnosis, respectively). The HR was 0.52 (95% CI 0.38-0.72) for all-cause mortality (ACM) and 0.83 (95% CI 0.70-0.98) for a composite of MI/stroke/ACM. Empagliflozin was associated with a similar risk of LLA and fractures, an increased risk of DKA (HR 1.71 [95% CI 1.08-2.71]) and a decreased risk of AKI (HR 0.60 [95% CI 0.43-0.85]). CONCLUSIONS In clinical practice, the initiation of empagliflozin versus a DPP-4 inhibitor was associated with a lower risk of HHF, ACM and MI/stroke/ACM, a similar risk of MI/stroke, and a safety profile consistent with documented information.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly G Brodovicz
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | | | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Bloom CI, Montonen J, Jöns O, Garry EM, Bhatt SP. First Maintenance Therapy for Chronic Obstructive Pulmonary Disease: Retrospective Analyses of US and UK Healthcare Databases. Pulm Ther 2022; 8:57-74. [PMID: 35015270 PMCID: PMC8861230 DOI: 10.1007/s41030-021-00179-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/22/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Inhaled corticosteroids (ICS) are often prescribed inappropriately alongside long-acting bronchodilators for chronic obstructive pulmonary disease (COPD). We aimed to investigate if prescribing habits in the US and UK differ from recommendations for initiation of COPD maintenance therapy. Methods We used healthcare data from the US IBM® MarketScan® and UK Clinical Practice Research Datalink databases to assess exacerbations and comorbidities in patients with COPD initiating first maintenance therapy (1MT) between 2015 and 2018. Patients with a recorded asthma diagnosis prior to initiation of 1MT were excluded. We evaluated time from recorded diagnosis of COPD until initiation of 1MT, and treatment regimen at 1MT (long-acting muscarinic antagonist [LAMA], long-acting β2-agonist [LABA], ICS, as monotherapy or in combination). Results In the US and UK, median (IQR) time between recorded COPD diagnosis and 1MT was 158 (12; 839) and 29 (1; 521) days, respectively. Among the 53,473 US patients and 8786 UK patients who initiated 1MT, 50.9% and 32.4% had ≥ 1 exacerbation in the previous year. In the US, 20% of patients initiated LAMA, 1% LABA, 13% LAMA/LABA, and 66% an ICS-containing regimen (49% LABA/ICS, 13% ICS, and 4% LAMA/LABA/ICS). In the UK, 53% of patients initiated LAMA, 4% LABA, 16% LAMA/LABA, and 27% an ICS-containing regimen (14% LABA/ICS, 9% ICS, and 4% LAMA/LABA/ICS). Conclusions At 1MT, two-thirds of patients in the US received ICS-containing therapies, with almost half on LABA/ICS. In contrast, less than one-third received ICS-containing therapy in the UK and more than half of patients received LAMA. In both countries, more patients received ICS-containing therapies at initiation of 1MT than would be expected based on their exacerbation history, suggesting overprescribing. Supplementary Information The online version contains supplementary material available at 10.1007/s41030-021-00179-0. Chronic obstructive pulmonary disease (COPD), a smoking-related lung disease, restricts airflow in the lungs, causing symptoms such as breathlessness and coughing. To control symptoms, patients use one or more types of inhaled ‘maintenance’ medication, which can be prescribed alone or together. When patients have a short-term worsening of symptoms, doctors often prescribe inhaled corticosteroids (ICS). We wanted to see whether doctors’ prescribing habits for maintenance inhalers are in line with clinical guidelines, so we analyzed data from a US health insurance database (~ 50,000 patients) and UK primary care medical records (~ 8000 patients). We focused on patients with a diagnosis of COPD who were prescribed their first maintenance therapy (1MT) between 2015 and 2018. We excluded people with a diagnosis of both COPD and asthma, as similar inhalers are used to treat these conditions, although the clinical decisions for when to prescribe them differ. The average time between COPD diagnosis and 1MT was longer in the US (158 days) than in the UK (29 days). A higher percentage of patients in the US (~ 65%) versus UK (~ 25%) were prescribed ICS as part of their treatment, and ICS use in both countries was higher than expected based on the guidelines, which recommend ICS only for patients with severe COPD who meet certain criteria. Our findings suggest overprescribing of ICS in both countries (particularly the US), meaning that some patients are being given medication without a known clinical benefit, which puts them at risk of side effects, possibly increasing unnecessary healthcare costs.
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Affiliation(s)
| | - Jukka Montonen
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Olaf Jöns
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Treatment Transitions in Chronic Obstructive Pulmonary Disease: Retrospective Analyses of US and UK Healthcare Databases. Pulm Ther 2022; 8:75-93. [PMID: 35015269 PMCID: PMC8861248 DOI: 10.1007/s41030-021-00180-7] [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: 09/22/2021] [Accepted: 11/22/2021] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Previous studies have reported that more patients receive inhaled corticosteroid (ICS)-containing therapies than would be expected based on exacerbation history, suggesting overprescribing. We aimed to describe patterns of treatment switching from first (1MT) to second maintenance therapy (2MT) among COPD patients in the US and UK. METHODS We used healthcare data from the US IBM® MarketScan® and UK Clinical Practice Research Datalink databases (2015 - 2018) to assess transitions between 1MT and 2MT among COPD patients. Patients with a recorded asthma diagnosis prior to 1MT were excluded. We assessed whether prescribed treatments (long-acting muscarinic antagonists [LAMA], long-acting β2-agonists [LABA], inhaled corticosteroids [ICS], as monotherapy or in combination) were consistent with global and national recommendations for COPD, identified patient characteristics associated with treatment transitions, and evaluated treatment duration. RESULTS Overall, 7028 patients in the US and 2461 in the UK initiated 2MT within a median (IQR) 160.0 (76.0; 335.0) and 218.0 (86.0; 428.0) days after 1MT, respectively. In the US, 33.6% of patients initiating 2MT had no recorded exacerbations in the previous year, whereas 23.1% had one and 43.3% had ≥ 2. In the UK, 54.9% of patients had no recorded exacerbations in the previous year, whereas 20.9% had one and 24.2% had ≥ 2. At 2MT, most patients switched to LAMA/LABA/ICS (26.1%) or LABA/ICS (25.8%) in the US, and LAMA/LABA (39.4%) or LAMA/LABA/ICS (27.8%) in the UK; 62.2% (US) and 47.5% of patients (UK) were prescribed ICS-containing regimens. The most common treatment transition from 1MT to 2MT was LABA/ICS to LAMA/LABA/ICS (13.0%) in the US; and LAMA to LAMA/LABA (32.5%) and LAMA to LAMA/LABA/ICS (14.3%) in the UK. CONCLUSIONS At 2MT, the proportion of patients on LAMA/LABA/ICS was similar between the US and UK, but treatment pathways were different.
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Kovesdy C, Schmedt N, Folkerts K, Bowrin K, Raad H, Batech M, Fried L. Predictors of cardio-kidney complications and treatment failure in patients with chronic kidney disease and type 2 diabetes treated with SGLT2 inhibitors. BMC Med 2022; 20:2. [PMID: 35000594 PMCID: PMC8744296 DOI: 10.1186/s12916-021-02191-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/17/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical practice guidelines recommend sodium-glucose co-transporter 2 inhibitors (SGLT2is) to mitigate adverse kidney and cardiovascular outcomes in patients with type 2 diabetes (T2D), including patients with comorbid chronic kidney disease (CKD), also referred to as diabetic kidney disease (DKD), who are at even higher risk. In this study, we sought to identify predictors of cardio-kidney events, cardio-kidney complications, and treatment failure (i.e., addition/initiation of a new T2D class, insulin, or discontinuation of SGLT2is) after new initiation of SGLT2is in patients with CKD and T2D (DKD). METHODS In this retrospective cohort study, we identified adult patients with DKD who initiated SGLT2is between April 1, 2012, and June 30, 2019, in Optum claims data. Outcome rates per 1000 person-years (PY) are reported with 95% confidence intervals (CIs). Cox proportional hazards regression identified patient characteristics associated with each outcome. RESULTS The study population consisted of 6389 initiators of SGLT2is. The rate of CV hospitalization was 26.0 (95% CI 21.6, 30.4) per 1000 PY. Baseline characteristics associated with higher risk of CV hospitalization included age, atrial fibrillation, peripheral vascular disease (PVD), and cancer. The rate of kidney hospitalization was 12.0 (95% CI 9.0, 15.0) per 1000 PY. The risk increased significantly with baseline evidence of heart failure, hyperkalemia, respiratory failure, depression, and use of loop diuretics. In total, 55.0% of all SGLT2i initiators discontinued treatment during the follow-up period. The rate of treatment failure was 510.5 (95% CI 492.9, 528.1) per 1000 PY. Analysis of key time-dependent SGLT2i-associated adverse events showed that experiencing diabetic ketoacidosis and volume depletion were associated with risk of treatment failure. CONCLUSIONS Our study demonstrated high rates of residual cardio-kidney outcomes and treatment failure in patients with DKD treated with SGLT2is. Patients with high baseline CV risk and the presence of certain conditions, such as atrial fibrillation, PVD, and heart failure, were at higher risk for cardio-kidney events. Further research is needed to assess the potential relationship between adverse events and SGLT2i treatment failure.
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Affiliation(s)
- Csaba Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee, Memphis, TN, USA
| | | | | | | | | | | | - Linda Fried
- 7E121 VA Pittsburgh Healthcare System, University of Pittsburgh, University Drive Center, Pittsburgh, PA, 15240, USA.
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Shin H, Schneeweiss S, Glynn RJ, Patorno E. Evolving channeling in prescribing SGLT-2 inhibitors as first-line treatment for type 2 diabetes. Pharmacoepidemiol Drug Saf 2022; 31:566-576. [PMID: 34985178 PMCID: PMC8989653 DOI: 10.1002/pds.5406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/16/2021] [Accepted: 12/31/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are increasingly being considered as first-line treatment for type 2 diabetes (T2D). The benefits of SGLT-2i from cardiovascular outcome trials may lead to preferential prescribing of SGLT-2i to patients at high cardiovascular risk, possibly causing confounding in non-randomized studies of SGLT-2i as first-line treatment. We assessed evolving imbalances in characteristics of patients starting SGLT-2i versus metformin as first-line monotherapy. METHODS Using claims data from two US commercial health insurance and Medicare, we identified patients with T2D aged ≥18 years (>65 years in Medicare) initiating first-line SGLT-2i or metformin from 2013 through 2019. Standardized differences (SDs) for patient characteristics were assessed during four consecutive calendar time blocks (T1:4/2013-12/2014; T2:1/2015-6/2016; T3:7/2016-12/2017; and T4:1/2018-12/2019). We also estimated the propensity score of receiving SGLT-2i versus metformin within each time block and evaluated time trends in model discrimination with c-statistics. RESULTS We identified 9113 initiators of first-line SGLT-2i and 810 348 initiators of first-line metformin. During T1, SGLT-2i initiators were younger (SD = -0.24) and less likely to have seen cardiologists (-0.07) with a similar prevalence of CVD (0.04) compared with metformin. During T4, patients were more balanced for age (-0.01). Cardiologist visits (0.08) and CVD (0.25) became more prevalent among SGLT-2i initiators. CONCLUSIONS When comparing initiators of first-line SGLT-2i versus metformin, imbalances in patient characteristics evolved from 2013 through 2019, particularly channeling SGLT-2i to individuals at high cardiovascular risk. Evolving channeling in prescribing first-line SGLT-2i should be expected and accounted for in non-randomized comparative effectiveness research.
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Affiliation(s)
- HoJin Shin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Wang SV, Schneeweiss S. Assessing and Interpreting Real-World Evidence Studies: Introductory Points for New Reviewers. Clin Pharmacol Ther 2022; 111:145-149. [PMID: 34416020 PMCID: PMC8771197 DOI: 10.1002/cpt.2398] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/13/2021] [Indexed: 01/03/2023]
Abstract
Nonrandomized real-world evidence (RWE) studies are conducted using healthcare data collected as part of clinical practice. As RWE studies are increasingly considered for regulatory, coverage, and other clinical decision making, nonspecialists will find themselves in the position of assessing the validity of RWE studies, a field that may be less familiar to them. This introductory guide provides conceptual guidance for reviewing RWE studies and is particularly directed at professionals for whom this is new or whose prior experience has primarily been in reviewing randomized controlled trial evidence. We focus on RWE studies that make causal inference, evaluating whether one treatment option is better, worse, or neutral compared to another. Although we provide citations to direct the reader to resources with more details on complex issues, this guide cannot substitute for years of training and expertise in the field.
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Affiliation(s)
- Shirley V. Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Correspondence: Shirley V. Wang ()
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Meid AD. Teaching reproducible research for medical students and postgraduate pharmaceutical scientists. BMC Res Notes 2021; 14:445. [PMID: 34886890 PMCID: PMC8656016 DOI: 10.1186/s13104-021-05862-8] [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: 10/07/2021] [Accepted: 11/26/2021] [Indexed: 11/10/2022] Open
Abstract
In medicine and other academic settings, (doctoral) students often work in interdisciplinary teams together with researchers of pharmaceutical sciences, natural sciences in general, or biostatistics. They should be fundamentally taught good research practices, especially in terms of statistical analysis. This includes reproducibility as a central aspect. Acknowledging that even experienced researchers and supervisors might be unfamiliar with necessary aspects of a perfectly reproducible workflow, a lecture series on reproducible research (RR) was developed for young scientists in clinical pharmacology. The pilot series highlighted definitions of RR, reasons for RR, potential merits of RR, and ways to work accordingly. In trying to actually reproduce a published analysis, several practical obstacles arose. In this article, reproduction of a working example is commented to emphasize the manifold facets of RR, to provide possible explanations for difficulties and solutions, and to argue that harmonized curricula for (quantitative) clinical researchers should include RR principles. These experiences should raise awareness among educators and students, supervisors and young scientists. RR working habits are not only beneficial for ourselves or our students, but also for other researchers within an institution, for scientific partners, for the scientific community, and eventually for the public profiting from research findings.
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Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Patorno E, Htoo PT, Glynn RJ, Schneeweiss S, Wexler DJ, Pawar A, Bessette LG, Chin K, Everett BM, Kim SC. Sodium-Glucose Cotransporter-2 Inhibitors Versus Glucagon-like Peptide-1 Receptor Agonists and the Risk for Cardiovascular Outcomes in Routine Care Patients With Diabetes Across Categories of Cardiovascular Disease. Ann Intern Med 2021; 174:1528-1541. [PMID: 34570599 PMCID: PMC8969214 DOI: 10.7326/m21-0893] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Both sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown cardiovascular benefits in placebo-controlled trials of patients with type 2 diabetes (T2D) and established cardiovascular disease (CVD). OBJECTIVE To evaluate whether SGLT2 inhibitors and GLP-1 RAs are associated with differential cardiovascular benefit among T2D patients with and without CVD. DESIGN Population-based cohort study. SETTING Medicare and 2 U.S. commercial claims data sets (April 2013 to December 2017). PARTICIPANTS 1:1 propensity score-matched adult T2D patients with and without CVD (52 901 and 133 139 matched pairs) initiating SGLT2 inhibitor versus GLP-1 RA therapy. MEASUREMENTS Primary outcomes were myocardial infarction (MI) or stroke hospitalization and hospitalization for heart failure (HHF). Pooled hazard ratios (HRs) and rate differences (RDs) per 1000 person-years were estimated, with 95% CIs, controlling for 138 preexposure covariates. RESULTS The initiation of SGLT2 inhibitor versus GLP-1 RA therapy was associated with a slightly lower risk for MI or stroke in patients with CVD (HR, 0.90 [95% CI, 0.82 to 0.98]; RD, -2.47 [CI, -4.45 to -0.50]) but similar risk in those without CVD (HR, 1.07 [CI, 0.97 to 1.18]; RD, 0.38 [CI, -0.30 to 1.07]). The initiation of SGLT2 inhibitor versus GLP-1 RA therapy was associated with reductions in HHF risk regardless of baseline CVD in patients with CVD (HR, 0.71 [CI, 0.64 to 0.79]; RD, -4.97 [CI, -6.55 to -3.39]) and in those without CVD (HR, 0.69 [CI, 0.56 to 0.85]; RD, -0.58 [CI, -0.91 to -0.25]). LIMITATION Treatment selection was not randomized. CONCLUSION Use of SGLT2 inhibitors versus GLP-1 RAs was associated with consistent reductions in HHF risk among T2D patients with and without CVD, although the absolute benefit was greater in patients with CVD. There were no large differences in risk for MI or stroke among T2D patients with and without CVD. PRIMARY FUNDING SOURCE Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School.
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Affiliation(s)
- Elisabetta Patorno
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
| | - Phyo T Htoo
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
| | - Robert J Glynn
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
| | - Sebastian Schneeweiss
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, Massachusetts (D.J.W.)
| | - Ajinkya Pawar
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
| | - Lily G Bessette
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
| | - Kristyn Chin
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
| | - Brendan M Everett
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
| | - Seoyoung C Kim
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.P., P.T.H., R.J.G., S.S., A.P., L.G.B., K.C., B.M.E., S.C.K.)
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Masarwa R, Lefebvre C, Platt RW, Filion KB. General practitioner prescribing trends among pediatric patients in the United Kingdom: 1998-2018. Pharmacoepidemiol Drug Saf 2021; 31:302-313. [PMID: 34708900 DOI: 10.1002/pds.5377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 10/13/2021] [Accepted: 10/22/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE To describe the prescribing trends of 17 therapeutic drug categories and the specific drug classes of systemic antibiotics, analgesics, and antidepressants in children and adolescents in the United Kingdom between 1998 and 2018. METHODS A population-based retrospective cohort study including children and adolescents aged 018 years. Overall and annual prescription rates per 10 000 person-years and corresponding 95% confidence intervals (CIs) were calculated. Rate ratios and 95% CIs were calculated to assess changes in prescription rates during the study period using Poisson regression. RESULTS Among 4 075 527 children and adolescents during the study period from 1998 to 2018, the prescribing rates increased by 15% for attention deficit hyperactivity disorder drugs (rate ratio: 1.15, 95% CI: 1.12-1.18), 14% for anxiolytics and hypnotics (rate ratio: 1.14, 95% CI: 1.13-1.16), and 8% for drugs for gastroesophageal reflux disease (GERD) (rate ratio: 1.08, 95% CI: 1.07-1.09). Prescribing rates decreased by 6% for cough preparations (rate ratio: 0.94, 95% CI: 0.92-0.95) and by 3% for analgesics (rate ratio: 0.97, 95% CI: 0.96-0.99). No meaningful changes were observed for systemic antibiotics (rate ratio: 1.02, 95% CI: 0.99-1.04). Among specific drug classes, prescribing rates decreased for broad-spectrum penicillins and cephalosporins, and they increased for selective serotonin reuptake inhibitors, opioids, and drugs for migraine. CONCLUSIONS Between 1998 and 2018, the prescribing of centrally acting drugs and drugs for GERD increased among pediatric patients, whereas prescribing of cough preparations and analgesics declined in this population.
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Affiliation(s)
- Reem Masarwa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Claire Lefebvre
- Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Robert W Platt
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
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Seesaghur A, Petruski-Ivleva N, Banks VL, Wang JR, Abbasi A, Neasham D, Ramasamy K. Clinical features and diagnosis of multiple myeloma: a population-based cohort study in primary care. BMJ Open 2021; 11:e052759. [PMID: 34615682 PMCID: PMC8496401 DOI: 10.1136/bmjopen-2021-052759] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Patients with multiple myeloma (MM) experience significant delays in diagnosis due to non-specific symptomatology. The aim of this study was to characterise the frequency and timing of clinical features in the primary care setting prior to MM diagnosis. DESIGN Population-based cohort study. SETTING Electronic health records data of approximately 17 million patients (2006-2016) within the UK Clinical Practice Research Datalink. PARTICIPANTS Patients aged ≥18 years with newly diagnosed MM (NDMM), no history of solid tumours and ≥2 years registration in a primary care practice prior to MM diagnosis. MAIN OUTCOME MEASURES Clinical features and symptoms including bone pain, skeletal-related events (SREs), investigation and confirmation of MM diagnostic CRAB criteria (hyperCalcaemia, Renal impairment, Anaemia, Bone lesions) during the 2 years prior to MM diagnosis; time between symptom manifestation and/or relevant investigation and diagnosis of MM. RESULTS Among 2646 patients with NDMM, 47.5% had a bone pain record during the 2-year period prior to MM diagnosis, mainly affecting the back. Regardless of baseline bone pain, investigations for serum calcium level were used in 36.4% of patients prior to MM diagnosis, followed by haemoglobin (65.6%) or renal function (74.1%). Median (Q1, Q3) time from first-recorded bone pain to MM diagnosis was 220 (80, 476) days. Median (Q1, Q3) time from first-recorded hypercalcaemia, renal impairment or anaemia to MM diagnosis was 23 (12, 46), 58 (17, 254) and 73 days (28, 232), respectively. An imaging investigation or referral for imaging was recorded for 60.0% of patients with bone pain/SRE and 32% without. CONCLUSIONS Nearly half of patients diagnosed with NDMM presented with bone pain approximately 7 months prior to MM diagnosis. Investigations to evaluate all CRAB criteria, including targeted imaging, were underused. Early recognition of myeloma clinical features and optimised use of investigations in primary care may potentially expedite MM diagnosis.
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Affiliation(s)
| | | | | | | | - Ali Abbasi
- Center for Observational Research (CfOR), Amgen Ltd, Uxbridge, UK
| | - David Neasham
- Center for Observational Research (CfOR), Amgen Ltd, Uxbridge, UK
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Fralick M, Schneeweiss S, Redelmeier DA, Razak F, Gomes T, Patorno E. Comparative effectiveness and safety of sodium-glucose cotransporter-2 inhibitors versus metformin in patients with type 2 diabetes: An observational study using data from routine care. Diabetes Obes Metab 2021; 23:2320-2328. [PMID: 34169619 DOI: 10.1111/dom.14474] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/03/2021] [Accepted: 06/18/2021] [Indexed: 12/28/2022]
Abstract
AIM To assess the effectiveness and safety of sodium-glucose cotransporter-2 (SGLT2) inhibitors in treatment-naïve patients compared with metformin. PARTICIPANTS AND METHODS We conducted a cohort study of US adults with type 2 diabetes mellitus who had not filled a prescription for a diabetes medication in the preceding year. We then identified patients who newly filled a prescription for an SGLT2 inhibitor or metformin between 2013 and 2018. The primary outcome was a composite of heart failure, myocardial infarction or stroke. Safety outcomes included hypoglycaemia, diabetic ketoacidosis, genital infection, lactic acidosis and acute kidney injury. After 1:1 propensity-score (PS) matching, proportional hazards models were fit to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS We identified 9964 individuals newly prescribed an SGLT2 inhibitor who were PS-matched to 9964 individuals newly prescribed metformin. The mean age was 54 years, 52% were women, and the duration of follow-up was 213 days for metformin and 147 days for SGLT2 inhibitors. The primary outcome occurred in 54 patients (7.2 events per 1000 person-years) who received an SGLT2 inhibitor, compared to 84 patients (8.5 per 1000 person-years) who received metformin (HR 0.82, 95% CI 0.58, 1.15). Similar results (HR 0.87, 95% CI 0.69, 1.09) were observed in an analysis with longer follow-up (ie, approximately 600 days). The rates of genital infection (HR 2.28, 95% CI 1.87, 2.78) and diabetic ketoacidosis (HR 1.58, 95% CI 0.92, 2.70) were higher for patients prescribed an SGLT2 inhibitor compared to metformin, while the rates of acute kidney injury (HR 0.94, 95% CI 0.60, 1.47) or hypoglycaemia (HR 0.83, 95% CI 0.48, 1.42) were not. CONCLUSIONS We observed a numerically lower rate of short-/mid-term cardiovascular events for patients newly prescribed an SGLT2 inhibitor compared to metformin, albeit with wide CIs that include the possibility of a null effect. SGLT2 inhibitors were associated with a higher rate of genital infection and diabetic ketoacidosis. Larger cohort studies and long-term clinical trials powered to assess cardiovascular events are necessary to understand the risk-benefit profile of SGLT2 inhibitors as first-line therapy for adults with type 2 diabetes mellitus.
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Affiliation(s)
- Michael Fralick
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Sinai Health, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES in Ontario, Toronto, Ontario, Canada
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Fahad Razak
- St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES in Ontario, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Schneeweiss S, Patorno E. Conducting Real-world Evidence Studies on the Clinical Outcomes of Diabetes Treatments. Endocr Rev 2021; 42:658-690. [PMID: 33710268 PMCID: PMC8476933 DOI: 10.1210/endrev/bnab007] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Indexed: 12/12/2022]
Abstract
Real-world evidence (RWE), the understanding of treatment effectiveness in clinical practice generated from longitudinal patient-level data from the routine operation of the healthcare system, is thought to complement evidence on the efficacy of medications from randomized controlled trials (RCTs). RWE studies follow a structured approach. (1) A design layer decides on the study design, which is driven by the study question and refined by a medically informed target population, patient-informed outcomes, and biologically informed effect windows. Imagining the randomized trial we would ideally perform before designing an RWE study in its likeness reduces bias; the new-user active comparator cohort design has proven useful in many RWE studies of diabetes treatments. (2) A measurement layer transforms the longitudinal patient-level data stream into variables that identify the study population, the pre-exposure patient characteristics, the treatment, and the treatment-emergent outcomes. Working with secondary data increases the measurement complexity compared to primary data collection that we find in most RCTs. (3) An analysis layer focuses on the causal treatment effect estimation. Propensity score analyses have gained in popularity to minimize confounding in healthcare database analyses. Well-understood investigator errors, like immortal time bias, adjustment for causal intermediates, or reverse causation, should be avoided. To increase reproducibility of RWE findings, studies require full implementation transparency. This article integrates state-of-the-art knowledge on how to conduct and review RWE studies on diabetes treatments to maximize study validity and ultimately increased confidence in RWE-based decision making.
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Affiliation(s)
- Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MAUSA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MAUSA
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Kirchgesner J, Desai RJ, Schneeweiss MC, Beaugerie L, Kim SC, Schneeweiss S. Emulation of a randomized controlled trial in ulcerative colitis with US and French claims data: Infliximab with thiopurines compared to infliximab monotherapy. Pharmacoepidemiol Drug Saf 2021; 31:167-175. [PMID: 34498314 DOI: 10.1002/pds.5356] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 08/04/2021] [Accepted: 09/03/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE To understand the validity of real-world evidence (RWE) studies in ulcerative colitis (UC), we emulated the SUCCESS randomized controlled trial (RCT) on the effectiveness of infliximab plus thiopurines, using US and French healthcare insurance claims data. METHODS The SUCCESS trial showed improved remission with infliximab plus thiopurines combined compared to infliximab monotherapy in patients with UC. Based on two US commercial claims databases (IBM MarketScan and Optum) and the French nationwide health insurance database (SNDS) from 2004 through 2019, all patients with UC who initiated combination therapy or infliximab alone were identified. The primary outcome of treatment failure was emulated by: Hospitalization related to UC or colectomy, treatment switch to another biologic or immunosuppressant, or use of corticosteroids 16 weeks after infliximab initiation. We estimated risk ratios with 95% confidence intervals after 1:1 propensity score (PS) matching. RESULTS Among 620 PS-matched pairs of combination therapy and infliximab monotherapy users, treatment failure occurred in 124 (20%) of patients initiating combination therapy and 170 (27%) during monotherapy. Like in SUCCESS, the risk of treatment failure was decreased with combination therapy in the overall cohort (RR = 0.73; 95% CI: 0.60-0.90). Findings were consistent across MarketScan, Optum, and SNDS: RR = 0.76 (0.57-1.02), 0.82 (0.54-1.24), and 0.61 (0.41-0.90). Similar results were observed for each component endpoint. CONCLUSIONS RWE results across three large claims databases were consistent with RCT findings. These findings provide support for the use of RWE to assess treatment effectiveness in UC.
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Affiliation(s)
- Julien Kirchgesner
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Department of gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Maria C Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Laurent Beaugerie
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Department of gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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