Trends in prescriptions for sedative-hypnotics among Korean adults: a nationwide prescription database study for 2011-2015

Development of a Web Application for Simulating Plasma Drug Concentrations in Patients with Zolpidem Intoxication

Zolpidem is a widely prescribed hypnotic Z-drug used to treat short-term insomnia. However, a growing number of individuals intentionally overdose on these drugs. This study aimed to develop a predictive tool for physicians to assess patients with zolpidem overdose. A population pharmacokinetic (PK) model was established using digitized data obtained from twenty-three healthy volunteers after a single oral administration of zolpidem. Based on the final PK model, a web application was developed using open-source R packages such as rxode2, nonmem2rx, and shiny. The final model was a one-compartment model with first-order absorption and elimination with PK parameters, including clearance (CL, 16.9 L/h), absorption rate constant (Ka, 5.41 h-1), volume of distribution (Vd, 61.7 L), and lag time (ALAG, 0.394 h). Using the established population PK model in the current study, we developed a web application that enables users to simulate plasma zolpidem concentrations and visualize their profiles. This user-friendly web application may provide essential clinical information to physicians, ultimately helping in the management of patients with zolpidem intoxication.

Sedative-hypnotics and osteoporotic fractures: A systematic review of observational studies with over six million individuals

We reviewed and meta-analyzed 20 observational studies to examine the relationship between sedative-hypnotic use and osteoporotic fractures. We searched PubMed, Embase, APA PsycINFO, and Web of Science™ for studies that used cohort, case-control, case-crossover, and self-controlled case series designs. We further assessed the quality of each study and performed meta-analyses of association estimates, e.g., odds ratios (ORs). The analysis included 6,084,083 participants and found a slight association between the use of sedative-hypnotics and osteoporotic fractures, with differing strength of associations between different classes of drugs and greater sedative-hypnotics exposure. The pooled estimates ORs for case-control studies were 1.33 (95% CI 0.98-1.80) with benzodiazepines (BZD) and any fractures, 1.32 (95% CI 1.05-1.66) with BZDs and hip fractures, and case-crossover studies were 1.15 (95% CI 0.95-1.41) with BZDs and any fractures, 1.41 (95% CI 1.08-1.85) with Z-drugs and any fractures. The study suggests that more research is needed to aid medical professionals in balancing this potential risk of osteoporotic fractures associated with sedative-hypnotic use against other reported adverse events and anticipated therapy outcomes.

The Impact of Moderate Earthquakes on Antidepressant Prescriptions in Ulsan, South Korea: A Controlled Interrupted Time Series Analysis

BACKGROUND

In 2016, two consecutive moderate magnitude earthquakes occurred in Ulsan, South Korea. Therefore, we aimed to investigate the impact of earthquakes on the mental health of residents in Ulsan.

METHODS

We used data from the 2015-2017 Korean Health Insurance Review & Assessment Service National Patient Sample. We conducted an interrupted time series analysis using location-based controls. Changes in the number of antidepressants, benzodiazepines, and zolpidem prescriptions in Ulsan were compared to controls. Overall changes in weekly prescriptions 1 year after the first earthquake, compared to a non-earthquake scenario, were estimated.

RESULTS

In antidepressant prescriptions, the increase in trend after an earthquake was significantly higher than controls. However, the changes in benzodiazepines and zolpidem prescribing were not significant. Overall, the impact of the earthquake on weekly antidepressant prescriptions at 1 year was estimated as a 1.32 (95% CI, 1.18-1.56) rate ratio compared to the non-earthquake scenario. This corresponded to an increase of 1,989.7 (95% CI, 1,202.1-3,063.0) in the number of prescriptions. Among subgroups, the increase was highest among males aged 20-39 years.

CONCLUSION

The moderate earthquake in Ulsan was associated with an increase in antidepressant prescriptions. The increase in the male group aged 20-39 was the highest. The impact may vary according to the context of the population.

Association Between Persistent Treatment of Alzheimer's Dementia and Osteoporosis Using a Common Data Model

Background and Purpose

As it becomes an aging society, interest in senile diseases is increasing. Alzheimer's dementia (AD) and osteoporosis are representative senile diseases. Various studies have reported that AD and osteoporosis share many risk factors that affect each other's incidence. This aimed to determine if active medication treatment of AD could affect the development of osteoporosis.

Methods

The Health Insurance Review and Assessment Service provided data consisting of diagnosis, demographics, prescription drug, procedures, medical materials, and healthcare resources. In this study, data of all AD patients in South Korea who were registered under the national health insurance system were obtained. The cohort underwent conversion to an Observational Medical Outcomes Partnership-Common Data Model version 5 format.

Results

This study included 11,355 individuals in the good persistent group and an equal number of 11,355 individuals in the poor persistent group from the National Health Claims database for AD drug treatment. In primary analysis, the risk of osteoporosis was significantly higher in the poor persistence group than in the good persistence group (hazard ratio, 1.20 [95% confidence interval, 1.09-1.32]; p<0.001).

Conclusions

We found that the good persistence group treated with anti-dementia drugs for AD was associated with a significant lower risk of osteoporosis in this nationwide study. Further studies are needed to clarify the pathophysiological link in patients with two chronic diseases.

Analysis of the prescription trends of potentially inappropriate medications in Korean older outpatients by sex: A retrospective study using data from the health insurance review and assessment service

This study aimed to determine the policy implications for drug management by identifying the prescription trends of potentially inappropriate medications (PIMs) in older outpatients. Considering the Drug Utilization Review and Korean version of the standards for PIMs based on the Beers Criteria, 141 ingredients were selected that spanned over 7 years of health insurance claims data analysis. During the study period, the number of patients and claims related to PIMs increased. Although the number of health insurance claims decreased in 2020 owing to coronavirus disease (COVID-19), it increased again in 2021. Tamsulosin was the most frequently prescribed drug for male patients, followed by alprazolam and zolpidem. For female patients, eperisone was the most frequently prescribed drug, followed by alprazolam, zolpidem, and etizolam. In Korea, health insurance claims for PIMs decreased in 2020 owing to the COVID-19 pandemic. However, an overall increasing trend was observed from 2015 to 2021. Moreover, during this period, the prescription trend of benzodiazepine-type drugs and zolpidem increased in both male and female patients. Therefore, management policies regarding PIMs and drug ingredients, such as benzodiazepines and zolpidem, are required.

Hypnotic prescription trends and patterns for the treatment of insomnia in Japan: analysis of a nationwide Japanese claims database

BACKGROUND

There is limited consensus regarding the optimal treatment of insomnia. The recent introduction of orexin receptor antagonists (ORA) has increased the available treatment options. However, the prescribing patterns of hypnotics in Japan have not been comprehensively assessed. We performed analyses of a claims database to investigate the real-world use of hypnotics for treating insomnia in Japan.

METHODS

Data were retrieved for outpatients (aged ≥ 20 to < 75 years old) prescribed ≥ 1 hypnotic for a diagnosis of insomnia between April 1^st, 2009 and March 31^st, 2020, with ≥ 12 months of continuous enrolment in the JMDC Claims Database. Patients were classified as new or long-term users of hypnotics. Long-term use was defined as prescription of the same mechanism of action (MOA) for ≥ 180 days. We analyzed the trends (2010-2019) and patterns (2018-2019) in hypnotics prescriptions.

RESULTS

We analyzed data for 130,177 new and 91,215 long-term users (2010-2019). Most new users were prescribed one MOA per year (97.1%-97.9%). In 2010, GABA_A-receptor agonists (benzodiazepines [BZD] or z-drugs) were prescribed to 94.0% of new users. Prescriptions for BZD declined from 54.8% of patients in 2010 to 30.5% in 2019, whereas z-drug prescriptions remained stable (~ 40%). Prescriptions for melatonin receptor agonist increased slightly (3.2% to 6.3%). Prescriptions for ORA increased over this time from 0% to 20.2%. Prescriptions for BZD alone among long-term users decreased steadily from 68.3% in 2010 to 49.7% in 2019. Prescriptions for ORA were lower among long-term users (0% in 2010, 4.3% in 2019) relative to new users. Using data from 2018-2019, multiple (≥ 2) MOAs were prescribed to a higher proportion of long-term (18.2%) than new (2.8%) users. The distribution of MOAs according to psychiatric comorbidities, segmented by age or sex, revealed higher proportions of BZD prescriptions in elderly (new and long-term users) and male (new users) patients in all comorbidity segments.

CONCLUSION

Prescriptions for hypnotics among new and long-term users in Japan showed distinct patterns and trends. Further understanding of the treatment options for insomnia with accumulating evidence for the risk-benefit balance might be beneficial for physicians prescribing hypnotics in real-world settings.

The Comparative Effectiveness and Safety of Insomnia Drugs: A Systematic Review and Network Meta-Analysis of 153 Randomized Trials

BACKGROUND

Pharmacological treatment is common in practice and widely used for the management of insomnia. However, evidence comparing the relative effectiveness, safety, and certainty of evidence among drug classes and individual drugs for insomnia are still lacking. This study aimed to determine the relative effectiveness, safety, and tolerability of drugs for insomnia.

METHODS

In this systematic review and network meta-analysis we systematically searched PubMed, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and ClinicalTrials.gov, from inception to January 10, 2022 to identify randomized controlled trials that compared insomnia drugs with placebo or an active comparator in adults with insomnia. We conducted random-effects frequentist network meta-analyses to summarize the evidence, and used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty, categorize interventionsand present the findings.

RESULTS

A total of 148 articles met our eligibility criteria; these included 153 trials which enrolled 46,412 participants and assessed 36 individual drugs from eight drug classes. Compared with placebo, both subjectively and objectively measured total sleep time were significantly improved with non-benzodiazepine (subjective: mean difference [MD] 25.07, 95% confidence interval [CI] 15.49-34.64, low certainty; objective: MD 22.34, 95% CI 7.64-37.05, high certainty), antidepressants (subjective: MD 54.40, 95% CI 34.96-75.83, low certainty; objective: MD 35.64, 95% CI 13.05-58.24, high certainty), and orexin receptor antagonists (subjective: MD 21.62, 95% CI 0.84-42.40, high certainty; objective: MD 31.81, 95% CI 2.66-60.95, high certainty); of which doxepin, almorexant, suvorexant, and lemborexant were among the relatively effective drugs with relatively good tolerability and lower risks of any adverse events (AEs). Both subjectively and objectively measured sleep onset latency were significantly shortened with non-benzodiazepines (subjective: MD - 10.12, 95% CI - 13.84 to - 6.40, moderate certainty; objective: MD - 12.11, 95% CI - 19.31 to - 4.90, moderate certainty) and melatonin receptor agonists (subjective: MD - 7.73, 95% CI - 15.21 to - 0.26, high certainty; objective: MD - 7.04, 95% CI - 12.12 to - 1.95, moderate certainty); in particular, zopiclone was among the most effective drugs with a lower risk of any AEs but worse tolerability. Non-benzodiazepines could significantly decrease both subjective and objective measured wake time after sleep onset (subjective: MD - 16.67, 95% CI - 21.79 to - 11.56, moderate certainty; objective: MD - 13.92, 95% CI - 22.71 to - 5.14, moderate certainty).

CONCLUSIONS

Non-benzodiazepines probably improve total sleep time, sleep onset latency, and wake time after sleep onset. Other insomnia drug classes and individual drugs also showed potential benefits in improving insomnia symptoms. However, the choice of insomnia drugs should be based on the phenotype of insomnia presented, as well as each drug's safety and tolerability. Protocol registration PROSPERO (CRD42019138790).

Physicians' attitudes toward hypnotics for insomnia: A questionnaire-based study

INTRODUCTION

Benzodiazepines and non-benzodiazepines are still widely prescribed despite safety concerns and the introduction of novel hypnotics (orexin receptor antagonists [ORA] and melatonin receptor agonists [MRA]), which may be influenced by physicians' attitudes toward hypnotics.

METHODS

A questionnaire survey was administered to 962 physicians between October 2021 and February 2022, investigating frequently prescribed hypnotics and the reasons for their selection.

RESULTS

ORA were the most frequently prescribed at 84.3%, followed by non-benzodiazepines (75.4%), MRA (57.1%), and benzodiazepines (54.3%). Compared to non-frequent prescribers of hypnotics, a logistic regression analysis showed that frequent ORA prescribers were more concerned with efficacy (odds ratio [OR]: 1.60, 95% confidence interval [CI]: 1.01-2.54, p = 0.044) and safety (OR: 4.52, 95% CI: 2.99-6.84, p < 0.001), frequent MRA prescribers were more concerned with safety (OR: 2.48, 95% CI: 1.77-3.46, p < 0.001), frequent non-benzodiazepine prescribers were more concerned with efficacy (OR: 4.19, 95% CI: 2.91-6.04, p < 0.001), and frequent benzodiazepine prescribers were more concerned with efficacy (OR: 4.19, 95% CI: 2.91-6.04, p < 0.001) but less concerned with safety (OR: 0.25, 95% CI: 0.16-0.39, p < 0.001).

DISCUSSION

This study suggested that physicians believed ORA to be an effective and safe hypnotic and were compelled to prescribe benzodiazepine and non-benzodiazepine frequently, choosing efficacy over safety.

Gender differences in the prevalence of and trends in sleep patterns and prescription medications for insomnia among US adults, 2005 to 2018

BACKGROUND

Evidence indicates that the burden of sleep disorders is increasing, yet recent trends have not been examined.

OBJECTIVE

To examine the prevalence of and trends in sleep patterns and medications commonly used for insomnia (MCUFI) in US adults from 2005 through 2018.

METHODS

A total of 39,749 participants aged 20 years or older from 7 consecutive National Health and Nutrition Examination Survey cycles during 2005-2018 were included.

RESULTS

The age-standardized prevalence of trouble sleeping and using MCUFI was higher in women than men, but men tended to sleep less (sleep duration <7 hours) and were more likely to have sleep disorders. The temporal trends in sleep disorders and MCUFI were similar in men and women, except that trouble sleeping increased more in men (P = 0.024). The prevalence of insufficient sleep decreased from 33.6% in women and 38.1% in men in 2005-2006 to 20.5% in women and 28.6% in men in 2017-2018. The prevalence of MCUFI use was 13.3% in women and 8.9% in men in 2005-2006, peaked at 15.2% for men and 17.0% for women in 2013-2014, and decreased slightly in 2015-2018.

CONCLUSION

The prevalence of trouble sleeping and MCUFI use was higher in women, while the prevalence of short sleep duration and sleep disorders was higher in men. Sleep disorders, abnormal sleep duration, and MCUFI use increased at a broadly similar pace in men and women, except that trouble sleeping increased more in men.

Long-term methylphenidate use for children and adolescents with attention deficit hyperactivity disorder and risk for depression, conduct disorder, and psychotic disorder: a nationwide longitudinal cohort study in South Korea

BACKGROUND

Methylphenidate (MPH) is the most frequently prescribed medication for the treatment of attention deficit hyperactivity disorder (ADHD). However, the safety of its long-term use remain unclear. In particular, real-world evidence of long-term MPH treatment regarding the risk of depression, conduct disorders, and psychotic disorders in children and adolescents is needed. This study aimed to compare the risks of depression, conduct disorder, and psychotic disorder between long- and short-term MPH treatments in children and adolescents.

METHODS

This population-based cohort study used a nationwide claims database of all patients with ADHD in South Korea. Patients aged less than 18 years who were prescribed MPH were included in the study. Long- and short-term MPH were defined as > 1 year, and < 1 year, respectively. Overall, the risk of developing depressive disorder, conduct disorder and oppositional defiant disorder (ODD), and psychotic disorder were investigated. A 1:2 propensity score matching was used to balance the cohorts, and the Cox proportional hazards model was used to evaluate the safety of MPH.

RESULTS

We identified 1309 long-term and 2199 short-term MPH users. Long-term MPH use was associated with a significantly lower risk of depressive (hazard ratio [HR], 0.70 [95% confidence interval [CI] 0.55-0.88]) and conduct disorders and ODD (HR, 0.52 [95% CI 0.38-0.73]) than short-term MPH use. Psychotic disorder was not significantly associated with long-term MPH use (hazard ratio [HR], 0.83 [95% confidence interval [CI] 0.52-1.32]).

CONCLUSIONS

Our findings suggest that long-term MPH use may be associated with a decreased risk of depression, conduct disorders and ODD. Moreover, the long-term use of MPH does not increase the risk of psychotic disorders. Long-term MPH administration may be considered as a favourable treatment strategy for children and adolescents with ADHD regarding depressive, conduct, and psychotic disorders.

Characteristics of adverse reactions among antipsychotic drugs using the Korean Adverse Event Reporting System database from 2010 to 2019

BACKGROUND

Retrospective studies using spontaneous reporting system databases have provided a great understanding of adverse drug reactions (ADRs) in the real world, complementing the data obtained from randomized controlled trials. However, there have been few reports on large-scale epidemiological studies on the adverse effects of antipsychotics in Asia.

AIM

This study aimed to investigate the characteristics of antipsychotic ADRs using a nationwide pharmacovigilance database.

METHODS

Data were collected from the Korea Adverse Event Reporting System database between 2010 and 2019. The study subjects were selected using the International Classification of Disease codes for diseases related to psychosis and Electronic Data Interchange codes for amisulpride, aripiprazole, clozapine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone. The causality assessment of "possible," "probable," or "certain" by the World Health Organization-Uppsala Monitoring Center System causality category was selected. All data were descriptively analyzed.

RESULTS

In total, 5067 adverse events associated with antipsychotic drugs were reported. The antipsychotics that commonly resulted in ADRs were quetiapine (47.7%), olanzapine (11.3%), and clozapine (10.7%). Serious ADRs were most commonly observed with clozapine. Gastrointestinal and central nervous system problems occurred within a month when ADRs were classified according to the time of onset. In contrast, metabolic and bone marrow-related symptoms occurred after long-term use. Sedation and nausea were the most common ADRs in children and adolescents, whereas constipation and dizziness were common in adults and the elderly.

CONCLUSIONS

This study extends our knowledge of antipsychotic ADRs in the Asian population.

Pregnancy and Neonatal Outcomes After Exposure to Alprazolam in Pregnancy

Alprazolam is a commonly prescribed benzodiazepine for anxiety or panic disorder, even in pregnant women. Information on the safety of alprazolam during pregnancy is insufficient. We aimed to evaluate pregnancy and neonatal outcomes after exposure to alprazolam during pregnancy. A prospective study was conducted on 725 pregnancies from January 2000 to December 2019. Participants were recruited through the Korean Mother-Safe Program, a service providing information on drug-induced teratogenic risk during pregnancy and breastfeeding. Exposed (N = 96) and non-exposed (N = 629) women to alprazolam during pregnancy were selected and followed-up until delivery. Pregnancy outcomes, including spontaneous abortion, still birth, low birth weight (LBW), preterm birth, Apgar score (at 1 and 5 min), and malformations were measured and compared. Multivariable logistic regression was performed to examine the association between alprazolam exposure and outcomes. The mean age was 32.9 (SD 4.0) years in the alprazolam-exposed group and 31.8 (SD 3.8) years in the unexposed group (p = 0.008). The alprazolam exposure group demonstrated a significantly higher likelihood of pregnancy and neonatal outcomes: spontaneous abortion (OR = 2.38; 95% CI 1.20–4.69), LBW (OR = 3.65; 95% CI 1.22–11.00), and Apgar score at 1 min ≤ 7 (OR = 2.19; 95% CI 1.02–4.67). There was no significant difference in congenital abnormalities between the exposure and non-exposure groups. Our findings confirmed that alprazolam exposure during pregnancy was significantly associated with adverse pregnancy and neonatal outcomes, including spontaneous abortion, low birth weight, and Apgar score at 1 min ≤ 7. Alprazolam during pregnancy should be appropriately regulated and monitored.

Zolpidem as a high risk factor for elderly suicide in South Korea

BACKGROUNDS

South Korea, a nation with rapidly aging population, has the highest suicide rates in the world, and the elderly have a suicide rate three times higher than the national average. We classified the drugs ingested for suicide attempts by age groups and compare the clinical outcomes between non-elderly and elderly patients who attempted suicide by ingesting drugs.

MATERIALS AND METHODS

Data were obtained from the nationwide Emergency Department-Based Injury Surveillance of the Korea Centers for Disease Control and Prevention, South Korea between January 2011 and December 2016.

RESULTS

There were 12,104 patients who attempted suicide by ingesting drugs, of whom the elderly (73.5%) ingested more sedatives and hypnotics than the non-elderly (53.9%); of these drugs, zolpidem ingestion was higher in the elderly than the non-elderly. Conversely, the non-elderly ingested more antipsychotics and antidepressants (15.9%) and analgesics (10.8%) than the elderly (7.4% and 2.8%, respectively). The elderly had longer hospital stay, higher intensive care unit (ICU) admission rate, and higher mortality rate than the non-elderly: more elderly patients (30.2%) were admitted to the ICU than the non-elderly (15.7%); the duration of hospital stays was 6.27 ± 11.35 days in the elderly and 8.94 ± 14.85 days in the non-elderly; and the mortality rate was 0.4% in the non-elderly and 3.0% in the elderly.

CONCLUSION

Findings suggest that zolpidem has become the greatest risk factor for the elderly Koreans in suicide attempts. Further prevention efforts are needed to prevent suicide among the elderly.

Trends in Prescriptions for Insomnia in a Province in China Between 2015 and 2019

BACKGROUND

The inappropriate use of pharmacological treatments for insomnia may increase patients' risk of serious adverse events. However, few epidemiological studies on the use of medications for insomnia in China have been conducted to date.

OBJECTIVE

We aimed to investigate the current pharmacological treatments for insomnia and guide the rational use of drugs.

METHODS

The prescription data of outpatients with insomnia between 2015 and 2019 in Zhejiang province were extracted from the Hospital Prescription Analysis Cooperative Project of China and evaluated. The demographic characteristics of insomnia and the proportion and prescription trends of different drugs were analyzed along with multidrug combinations for insomnia.

RESULTS

The number of patients with insomnia who were prescribed medications for insomnia increased from 2,385 in 2015 to 3,919 in 2019, with an increase of 64.32%, whereas the mean age of these patients decreased from 64.07 years to 60.94 years. There were nearly 1.42 times as many female patients prescribed medications for insomnia as male patients, and female patients tended to be younger than male patients. Benzodiazepines (53.99%) were the most common type of medicine for insomnia. The incidence of benzodiazepine usage decreased significantly yearly (P < 0.01), whereas the incidences of non-benzodiazepine receptor agonist (nBZRA) and antidepressant usage increased (P < 0.05). The most common benzodiazepine, nBZRA, antidepressant, and antipsychotic were estazolam, zolpidem, trazodone, and olanzapine, respectively. A total of 13.97% of outpatients with insomnia were prescribed multiple drugs for insomnia, even though nearly half of the drug combinations had similar pharmacological mechanisms.

CONCLUSIONS

Benzodiazepines remained the most common medication for insomnia, but the prescription rates of nBZRAs and antidepressants increased. Attention should be paid to multidrug combinations for insomnia, which may lead to an increased risk of serious adverse effects.

Analysis of Medical Services for Insomnia in Korea: A Retrospective, Cross-Sectional Study Using the Health Insurance Review and Assessment Claims Data

This study aimed to analyze current trends in healthcare utilization and medication usage in patients with insomnia. We reviewed the National Patient Sample data from the Health Insurance Review and Assessment Service to determine healthcare utilization in patients diagnosed with insomnia (International Classification of Diseases-10 codes G470, F510) between January 2010 and December 2016. There were 87,470 patients enrolled in this study who utilized healthcare services at least once during the 7-year period. Healthcare utilization trends, Korean and Western medicine (KM and WM, respectively) therapies utilized, comorbidities, and socioeconomic data were analyzed. The number of patients seeking WM or KM care for insomnia increased annually. Adults aged ≥45 years accounted for 73% of the cohort, and there were more female than male patients. KM treatment including acupuncture was the most common in KM (65.29%), while examination was the most common WM treatments (49.31%). In pharmacological therapy, sedatives and hypnotics were the most common (41.08%), followed by antianxiety (19.50%), digestive system and metabolism-related drugs (7.77%). The most common comorbidities were mental health disorders (50.56%) in WM but musculoskeletal disorders in KM (35.67%). Code G470 was used more frequently than code F510, and the difference was more evident in KM than in WM. The findings will provide valuable information for both clinicians and researchers.

Impact of drug formulation on outcomes of pharmaceutical poisoning in children aged 7 years or younger: A retrospective observational study in South Korea

Pharmaceutical poisoning in children is almost unintentional and there are various types of drug out of curiosity. Understanding the attractive features and formulation of drugs related to poisoning in younger children may be helpful in treatment and prevention of poisoning. To investigate the impact of drug formulation on outcomes of pharmaceutical poisoning in young children.We retrospectively reviewed the data of pharmaceutical exposures among children who were registered in a Korean 23-center, emergency department (ED) based registry from 2011 to 2016. Our study was conducted on preschool children aged 0 to 7 years. According to the formulation and category of the ingested drugs, the exposures were divided into the "tablet and capsule (TAC)" and "syrup" groups. In the TAC group, we additionally recorded data on the shape, color, and size of the drugs. The ED outcomes, such as hospitalization and length of stay, were compared between the 2 groups.Among the 970 enrolled exposures, 674 (69.5%) were classified into the TAC group. In this group, hormones/hormone antagonists (18.5%) were the most commonly ingested, followed by central nervous system drugs (17.1%). In the syrup group, antihistamines (28.4%) were the most commonly ingested, followed by respiratory drugs (24.3%). The TAC group showed a higher hospitalization and transfer rate to tertiary centers than the counterpart (TAC, 18.0% vs syrup, 11.5%, P = .03) without a significant difference in the length of stay (TAC, 173.5 minutes [interquartile range, 95.0-304.0] vs syrup, 152.5 [77.5-272.0]; P = .08). No in-hospital mortality occurred in the exposures. Round-shaped and chromatic TACs, accounting for 91.7% (618) and 56.1% (378), respectively, were more commonly ingested. The median size of the TACs was less than 1.0 cm.Young children who visited the ED ingested TACs more frequently than syrups, particularly small, round-shaped, or chromatic drugs, leading to a higher hospitalization rate. Our findings can contribute to prevention strategies and safety education on childhood drug poisoning.

Effect of CYP3A4 metabolism on sex differences in the pharmacokinetics and pharmacodynamics of zolpidem

To investigate pharmacokinetic and pharmacodynamic differences of zolpidem between males and females and their causes, including CYP3A4 activity. A single oral dose of zolpidem (10 mg) was administered to 15 male and 15 female healthy subjects. Blood samples were collected up to 12 h post-dose to determine plasma zolpidem concentrations. Pharmacokinetic parameters were obtained using non-compartmental analysis. Digit symbol substitution test, choice reaction time, and visual analog scale of sleepiness were used to evaluate pharmacodynamics. We measured CYP3A4 activity using 4β-hydroxycholesterol, an endogenous metabolite. Mean maximum plasma concentration and area under the plasma concentration–time curve were higher for females than for males (9.9% and 32.5%, respectively); other pharmacokinetic parameters showed no significant differences. Pharmacodynamic scores for females showed delayed recovery compared with that for males. CYP3A4 activity was higher in females than in males (p = 0.030). There was no serious adverse event, and adverse event incidence was not different between the sexes. Zolpidem exposure was about 30% higher in females than in males. Delayed pharmacodynamic score recovery in females could be related to higher zolpidem concentrations. Although apparent clearance was lower in females, systemic clearance might not be the cause of the different exposures to zolpidem.

Electronic dashboard-based remote glycemic management program reduces length of stay and readmission rate among hospitalized adults

AIMS/INTRODUCTION

Currently, the impact of hospital-wide glycemic control interventions on length of hospital stay (LOS) and readmission rates are largely unknown. We investigated the impact of a 4-year hospital-wide remote glycemic management program on LOS and 30-day readmission rates among hospitalized adults who received glucose monitoring.

MATERIALS AND METHODS

In this retrospective study, hospitalized patients who received glucose monitoring were classified into groups 1 (high glucose variability), 2 (hypoglycemia), 3 (hyperglycemia) and 4 (relatively stable). The monthly percentage changes, and average monthly percentage changes of hyperglycemia, hypoglycemia and treat to target were determined using joinpoint regression analysis.

RESULTS

A total of 106,528 hospitalized patients (mean age 60.9 ± 18.5 years, 57% men) were enrolled. We observed a significant reduction in the percentage of inpatients in poor glycemic control groups (groups 1, 2 and 3, all P < 0.001), and a reciprocal increase in the relatively stable group (group 4) from 2016 to 2019. We found a significant reduction in LOS by 11.4% (10.5-9.3 days, P = 0.002, after adjustment for age, sex, and admission department). The 30-day readmission rate decreased from 29.9% to 29.3%, mainly among those in group 4 in 2019 (P < 0.001 after adjustment of sex, age, admission department and LOS).

CONCLUSIONS

Improved glycemic control through a hospital-wide electronic remote glycemic management system reduced LOS and 30-day readmission rates. Findings observed in this study might be associated with the reduction in cost of avoidable hospitalizations.

Prescribing Pattern of Hypnotic Medications in Patients Initiating Treatment at Japanese Hospitals: A Nationwide, Retrospective, Longitudinal, Observational Study Using a Claims Database

Background

Prolonged treatment of insomnia using benzodiazepine (BZD) receptor agonists, including BZD and non-BZD hypnotic drugs, can cause drug dependence, tolerance, abuse and other adverse events. These side effects are more common and/or severe in older adults taking different hypnotic drugs concomitantly. Therefore, a single prescription is limited to 30 daily doses for most BZD receptor agonists and restrictions apply to the prescription of more than three types of hypnotic drugs in Japan. Little is known, however, about the real-world prescribing pattern of hypnotic drugs in Japan.

Objective

We analysed prescribing patterns for hypnotic drugs in Japan to evaluate whether real-world use differs from guideline recommendations.

Methods

In this nationwide, retrospective, longitudinal, observational study, we analysed the types of hypnotic drugs prescribed, duration of medication and treatment setting in a subset of hospitals in Japan using a hospital-based administrative claims database (Medical Data Vision). Patients initiating treatment with hypnotic drugs between January 2012 and December 2016 were included in the analyses to assess the duration of medication and occurrence of co-prescription of a second and third hypnotic drug, within a year from prescription of the first hypnotic drugs.

Results

In 261,167 patients analysed, the first hypnotic drugs prescribed were BZDs (59.7%), non-BZDs (36.8%), a melatonin receptor agonist [MRA] (3.1%) and an orexin receptor antagonist [ORA] (0.4%). Benzodiazepine and non-BZD hypnotic drugs were mostly prescribed in inpatient settings (57.7% and 63.0%, respectively) and the MRA and ORA mostly in outpatient settings (62.6% and 65.4%, respectively). The departments that prescribed the most patients their first hypnotic drugs were internal medicine (23.6%), general surgery (11.8%), orthopaedic surgery (11.4%) and urology (5.3%). Of the total prescriptions of MRA and ORA as the first hypnotic drugs, 22.0% and 31.8% were in internal medicine, 4.4% each in general surgery, 6.0% and 4.5% in orthopaedic surgery, 9.7% and 4.4% in neurology, and 10.1% and 12.2% in psychiatry departments, respectively. Mean duration of medication was 1.13 months for non-BZDs, 1.15 months for BZDs, 1.29 months for the ORA and 1.83 months for the MRA. Overall, 5.3% (95% confidence interval 5.2–5.4) of patients were prescribed a second hypnotic drug; of these, 8.4% (95% confidence interval 8.0–8.9) were prescribed at least three hypnotic drugs within a year. Patients who were prescribed three or more hypnotic drugs received higher doses of the first drug than patients who received fewer hypnotic drugs.

Conclusions

Benzodiazepine receptor agonists were the most common hypnotic drugs prescribed as the first drug to patients in Japan. Further education and awareness may be needed on the risk of complications and adverse events associated with these therapies. The duration of BZD receptor agonist use was shorter than for the MRA and ORA, in accordance with prescribing guidelines. Long-term use and co-prescribing of hypnotic drugs were also uncommon.

Elucidating the Relationship Between Insomnia, Sex, and Cardiovascular Disease

Sex differences in cardiovascular disease (CVD) mortality have been attributed to differences in pathophysiology between men and women and to disparities in CVD management that disproportionately affect women compared to men. Similarly, there has been investigation of differences in the prevalence and presentation of insomnia attributable to sex. Few studies have examined how sex and insomnia interact to influence CVD outcomes, however. In this review, we summarize the literature on sex-specific differences in the prevalence and presentation of insomnia as well as existing research regarding the relationship between insomnia and CVD outcomes as it pertains to sex. Research to date indicate that women are more likely to have insomnia than men, and there appear to be differential associations in the relation between insomnia and CVD by sex. We posit potential mechanisms of the relationship between sex, insomnia and CVD, discuss gaps in the existing literature, and provide commentary on future research needed in this area. Unraveling the complex relations between sex, insomnia, and CVD may help to explain sex-specific differences in CVD, and identify sex-specific strategies for promotion of cardiovascular health. Throughout this review, terms “men” and “women” are used as they are in the source literature, which does not differentiate between sex and gender. The implications of this are also discussed.

New methodological approaches were able to effectively reduce immeasurable time bias in case-only designs

OBJECTIVES

The objective of this study was to assess approaches to reduce immeasurable time bias in case-crossover (CCO), case-time-control (CTC), and case-case-time-control (CCTC) designs.

STUDY DESIGN AND SETTING

We used Korea's health care database that has inpatient and outpatient prescriptions and an empirical example of benzodiazepines and mortality among the elderly. We defined our unbiased exposure setting using all prescriptions and a pseudo-outpatient setting using outpatient records only. In the pseudo-outpatient setting, we assessed 10 approaches of restricting, adjusting, stratifying, or weighting on hospitalization-related factors. We conducted conditional logistic regression to estimate odds ratio (OR) with 95% confidence intervals (CI), where an approach was considered effective when its OR was within the unbiased exposure setting OR's 95% CI.

RESULTS

Immeasurable time bias negatively biased the unbiased exposure setting's OR in all three case-only designs, overestimating the protective effect of benzodiazepines on mortality. Of the 10 approaches examined, stratifying the proportion of hospitalized time in 0.01 intervals most effectively repaired the bias in the CCO (OR 1.25, 95% CI 1.10-1.43) and CTC analyses (1.11, 0.95-1.30); no approach was effective in the CCTC analysis.

CONCLUSION

Stratifying the proportion of hospitalized time in 0.01 intervals best approximated the unbiased exposure setting estimate by overcoming the significant impact of immeasurable time bias in CCO and CTC designs.

Temporal association between zolpidem medication and the risk of suicide: A 12-year population-based, retrospective cohort study

There have been concerns about abuse and unnecessary chronic administration of zolpidem, and zolpidem's relation to suicide risk. To investigate the temporal association of zolpidem with the risk of suicide, we conducted a 12-year, population-based, retrospective cohort study on the National Health Insurance Service-National Sample Cohort (NHIS-NSC), South Korea. Data were collected from 2002 to 2013 from the NHIS-NSC, and data cleaning was performed for 1,125,691 subjects. Cox proportional hazards regression analysis was used to investigate the correlation over time between zolpidem medication and suicide. Over intervals commencing after 80 months of observation, the adjusted hazard ratio of suicides associated with the use of the zolpidem was 2.01 (95% CI: 1.58-2.56; p < 0.001). The mean cumulative number of days of zolpidem prescription was significantly longer in the suicide group than in the non-suicide group after log-transformation (p = 0.005). Cases of chronic use of zolpidem (over six months or one year) were significantly more common in the suicide group compared to the non-suicide group (p = 0.002 and 0.005, respectively). Subjects who received zolpidem medication had a significantly higher risk of suicide after at least 80 months of observation, suggesting a long-term increased suicide risk associated with insomnia exposed to zolpidem medication.

Efficacy and safety of TCM Yangxin Anshen Therapy for insomnia: A systematic review and meta-analysis

BACKGROUND

Traditional Chinese Medicine (TCM) has gradually drawn the attention of clinicians as an alternative choice for insomniacs and TCM Yangxin Anshen Therapy (TYAT) is a crucial therapy of treating insomniacs. The purpose of this study was to evaluate the efficacy and safety of TYAT for insomnia.

METHODS

Seven electronic databases were searched from inception to July 2019. Two authors independently identified Randomized Controlled Trials (RCTs), extracted data and assessed risk of bias by Cochrane risk bias assessment tool. Comprehensive meta-analysis was conducted with the Review Manager for eligible and appropriate studies.

RESULTS

Fourteen trials (1549 participants) were finally included in this study. The included studies were of moderate-to-high quality. Twelve trials reported the specific methods of random sequence generation, and 4 of them used the allocation concealment. Blinding of participants and personnel were used in 7 studies, and blinding of outcome assessment was performed in 3 studies. The main meta-analysis showed: CONCLUSION:: TYAT is an effective alternative therapy for insomnia, and its clinical application appears safe. The conclusions of this paper have a certain reference value for further research and clinical practice.

TRIAL REGISTRATION NUMBER

PROSPERO CRD 42019135115.