High rates of adverse effects and patient unawareness of withdrawn lipid-lowering drug combination in a public hospital clinic

Pattern of statin exposures reported to Texas poison centers, 1998-2004

Information on the management of potentially adverse exposures to statins is limited. This study examined the pattern of 2331 statin exposures reported to Texas poison control centers during 1998-2004. In particular comparisons were made between exposures among pediatric (age < or = 5 yr) and adult (age > or = 20 yr) patients. The number of exposures increased from 134 in 1998 to 516 in 2004. Of the total exposures, 55% were to statins alone. Of the exposures to statins alone, 57% of the patients were < or = 5 yr of age and 22% were > or = 60 yr of age. The majority of exposures to statins alone (a) involved female patients (53%), (b) were unintentional (94%), (c) occurred at home (91%), (d) were managed on-site/at home (89%), and (e) had a final medical outcome classified as no effect (94%). Pediatric and adult patients differed with respect to patient gender (45 versus 66% female), exposure reason (100 versus 88% unintentional, 1 versus 75% therapeutic error), exposure site (14 versus 2% at other residence), final medical outcome (4 versus 11% minor effect, none versus 4% moderate effects), report of specific adverse clinical exposures (0.2 versus 5% neurological effects, none versus 1% cardiovascular effects), and listed treatments (60 versus 24% decontamination by dilution, 13 versus 6% decontamination by food). In conclusion, reported statin exposures are increasing. The majority of potentially adverse statin exposures reported to poison control centers may be successfully managed at home with favorable outcomes. The pattern of exposures differs with age.

The CoPrescription of Contraindicated Drugs With Statins: Continuing Potential for Increased Risk of Adverse Events

The objectives of this study were to determine the extent of coprescribing of statins with medications that may increase the risk of adverse events and to identify associated patient and prescriber characteristics. The authors conducted a retrospective cohort study in a large database representative of the U.S. prescription-filling population. The authors studied the U.S. retail prescription environment as reflected in prescriptions dispensed. Patients filling a prescription for a statin between October 1, 2001, and September 30, 2002 were studied. A coprescription for medications of interest as reflected in the warnings and precautions of statin product package inserts was studied: fibric acid, niacin, azole antifungal, macrolide antibiotics, nefazodone, protease inhibitors, verapamil, or warfarin within 3 weeks of a statin prescription. Patient and prescriber characteristics and proportion of coprescribing events attributable to the same prescriber were examined.A total of 5,637,918 patients filled a statin prescription during the 12-month study period. Nearly 19% had concomitant use of a medication with warnings and/or precautions for coprescribing (coprescription event). Coprescription was highest for fibrates, macrolides, and niacin accounting for 19.3%, 17.4%, and 9.4%, respectively, and did not differ across statins. One-third of coprescribing events involved same-day prescriptions, 57% occurred within 7 days of the index statin prescription, and 71.2% of all coprescription events originated from the same prescriber. Coprescribing of medications not compatible with statins occurs frequently. The extent of coprescribing indicates the need for additional intervention to assure that the risk of untoward effects is mitigated.

Responding rapidly to FDA drug withdrawals: design and application of a new approach for a consumer health website

Background

Information about drug withdrawals may not reach patients in a timely manner, and this could result in adverse events. Increasingly, the public turns to consumer health websites for health information, but such sites may not update their content for days or weeks following important events like Food and Drug Administration (FDA) drug withdrawal actions. There is no recognized standard for how quickly consumer health websites should respond to such events, and reports addressing this issue are lacking.

Objective

The objective of this study was to develop and implement an approach to enhance the efficiency with which a consumer health website (NetWellness.org) responds to FDA drug withdrawal actions.

Methods

Evaluation of the current approach used by NetWellness staff to update content affected by FDA action revealed a slow process driven by the goal of performing thorough and comprehensive review and editing. To achieve our desired goal of accurately updating affected content within 24 hours of FDA action, we developed a strategy that included rapid updating of affected Web pages with warning boxes and hyperlinks to the information about the withdrawal. With the next FDA withdrawal event, that of valdecoxib (Bextra) on April 7, 2005, we applied this new approach, observed the time and resource requirements, and monitored the rate at which consumers viewed the updated information to gauge its potential impact.

Results

Application of the new approach allowed one person to modify the affected Web pages in less than 1 hour and within 18 hours of the FDA announcement. Using the old strategy, response to a similar event, the withdrawal of rofecoxib (Vioxx) 6 months earlier, had taken over 3 weeks and the efforts of several personnel. Updated valdecoxib content received 188 hits within the first month and 4285 hits within 1 year.

Conclusions

Rapid updating of a consumer health website's content in response to an FDA drug withdrawal event was easily accomplished by applying the approach described. This allowed consumers to view accurate information regarding the withdrawn drug much sooner than would otherwise have been the case. Given that consumers increasingly turn to websites for their health information, adoption of a rapid response standard for important health events like FDA drug withdrawals should be considered by the consumer health informatics community.

The cerivastatin withdrawal crisis: a “post-mortem” analysis

In August 2001, cerivastatin was removed from European and USA markets because of a higher risk of rhabdomyolysis associated with its use in comparison with other statins. The objective of this study was to compare cholesterol-lowering drug use in Italy before and after the withdrawal of cerivastatin from the market, and to evaluate if the withdrawal influenced patients compliance and physicians prescribing habits. After August 2001, 48% of cerivastatin users discontinued any statin treatment. The major risk factor for discontinuation was a concomitant use of fibrate during the first 7 months of 2001 (OR = 2.3; 95% CI = -2.9). Comparing the discontinuation of statin therapy between 2001 and 2000 we can estimate that there was a 5% increase, corresponding to about 200,000 patients, who discontinued statin therapy during autumn 2001 because of cerivastatin emergency.

Failure to continue lipid-lowering drug use following the withdrawal of cerivastatin

BACKGROUND

Persistence with lipid-lowering drug use is important in order for patients to gain full treatment benefit. The withdrawal of cerivastatin from the market may have affected persistence due to the fear of serious adverse effects.

OBJECTIVE

To assess failure of patients to continue lipid-lowering drug use following the withdrawal of cerivastatin.

METHODS

A cohort study including 3.5 months follow-up after the withdrawal of cerivastatin in August 2001 was conducted using data from community pharmacies in The Netherlands, covering a population of approximately 600,000 subjects. Patients selected for inclusion in the index group were current users of cerivastatin on August 10, 2001 (the date that cerivastatin was withdrawn from the market). Reference patients were gender, age and pharmacy or region matched patients who were using any HMG-CoA reductase inhibitor other than cerivastatin on the same date. The main outcome measure was discontinuation of lipid-lowering drug use. To assess whether discontinuation had increased in the reference group, discontinuation rates were compared with discontinuation rates in the previous year. Data on these rates in 2000 were obtained from the population-based PHARMO record linkage system.

RESULTS

A total of 31 pharmacies of the research network (response rate 86.1%) provided medication histories of 234 current users of cerivastatin and 431 matched patients using any other HMG-CoA reductase inhibitor. In addition, 352 current users of cerivastatin and 704 matched patients using any other HMG-CoA reductase inhibitor were obtained from the PHARMO database. Overall, 13.7% of subjects in the cerivastatin group (n=586) and 9.5% in the reference group (n=1135) discontinued lipid-lowering medication (adjusted odds ratio [OR] 1.44; 95% CI 1.04-2.00). The rate of discontinuation in the reference group was comparable to this rate in the previous year. Discontinuation was more prevalent in women who had been taking cerivastatin (adjusted OR 1.74; 95% CI 1.09-2.78), those receiving low doses of cerivastatin (adjusted OR 2.45; 95% CI 1.20-4.97), those who received their last cerivastatin prescription from a specialist (adjusted OR 1.92; 95% CI 1.02-3.60) and those who had recently started using cerivastatin (adjusted OR 2.80; 95% CI 0.98-7.98), although the latter was not statistically significant.

CONCLUSIONS

Failure to continue lipid-lowering drug use was higher in patients using cerivastatin than in users of other HMG-CoA reductase inhibitors, especially in women, those using low doses of HMG-CoA reductase inhibitors and recent starters of lipid-lowering medication. The prevention of unwarranted discontinuation of drugs due to market withdrawal should be a joint task of healthcare providers, industry and regulatory bodies.

Early detection of drug interactions utilizing a computerized drug prescription handling system-focus on cerivastatin-gemfibrozil

OBJECTIVES

Based on the recent cerivastatin experience, we retrospectively evaluated the effect of notifying a drug alert utilizing a computerized drug-handling system.

METHODS

The evaluation was carried out during three periods: period I corresponded to all prescriptions issued during April, 2001 ("baseline period"), before the Spanish Drug Agency issued alerts on the concomitant therapy with cerivastatin and gemfibrozil; period II (June) corresponded to a time in which a first informative note had been released; and period III (July) after the second warning alert was issued.

RESULTS

Data collected included the reading of 2,693,656 drug prescriptions, 1,937,083 (71.9%) of which contained patient information. Forty-four patients received combined therapy with cerivastatin and gemfibrozil over the three periods, yielding 55 exposures: 27 during the baseline period, and 28 between periods II and III, when the alert bulletins had already been released. Moreover, 41.6% of doctors included in the follow-up repeated the hazardous prescription during those two periods.

CONCLUSIONS

The effect of the informative notes about the risk of prescribing cerivastatin and gemfibrozil concomitantly on doctors' prescribing habits was limited. The system for screening information from drug prescriptions presented herein allows the early detection of drug interactions by identifying the doctors who issue hazardous prescriptions as well as patients at the highest risk of adverse drug reactions, thus allowing a personal feedback with both of them.