Gender Aspects in Cardiovascular Pharmacology

Sex Differences in Cardiovascular Management: A Call for Better Acknowledgment-Part 1 Pharmacological Differences in Women and Men; How Relevant Are They?

BACKGROUND

Sex differences (SDs) in pharmacology of cardiovascular (CV) drugs have been described previously; however, paradoxically, there are scarce recommendations in therapy based on these differences. It is of utmost importance to identify whether these SDs determine a modified clinical response and the potential practical implications for this, to provide a base for personalized medicine.

AREA OF UNCERTAINTY

The aim of this article was to outline the most important pharmacological drivers of cardiovascular drugs that differ between women and men, along with their implications and challenges in clinical practice.

DATA SOURCES

A detailed assessment of English-written resources reflecting SDs impact in CV drug pharmacology was performed using PubMed and Embase databases.

RESULTS

Despite large variations in CV drug pharmacokinetics and pharmacodynamics in individuals, correcting for height, weight, surface area, and body composition compensate for most "sex-dependent" differences. In addition, individual, cultural, and social factors significantly impact disease management in women versus men. Gender-biased prescribing patterns and gender-dependent adherence to therapy also influence outcomes. The development of sex-specific guidelines requires that they should reflect the SDs implications for the management of a disease and that the evidence should be carefully evaluated as to whether there is an adequate representation of both sexes and whether sex-disaggregated data are reported.

CONCLUSIONS

Pharmacological drivers are under the influence of an impressive number of differences between women and men. However, to establish their significance in clinical practice, an adequate representation of women in studies and the reporting of distinct results is mandatory.

Age- and Sex-Specific Disparities in Outcomes After Ticagrelor Versus Clopidogrel in East Asian Patients

It is unknown whether there are age- and gender-related differences in the safety and efficacy of potent P2Y12 inhibitors in East Asian populations with a different bleeding or ischemic propensity. Using data from the TICAKOREA (Ticagrelor Versus Clopidogrel in Asian/Korean Patients with ACS Intended for Invasive Management) trial comparing ticagrelor versus clopidogrel for 800 Korean patients with acute coronary syndrome, the safety and efficacy outcomes were compared according to age (<75 vs ≥75 years) and gender (men vs women). The primary bleeding end point was clinically significant bleeding, and the primary ischemic end point was a major adverse cardiovascular event (MACE) at 12 months. The incidences of clinically significant bleeding were significantly higher after ticagrelor than after clopidogrel in patients aged <75 years (adjusted hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.40 to 4.67) but not in patients aged ≥75 years (adjusted HR 1.1, 95% CI 0.40 to 3.38). The incidences of MACEs were significantly higher after ticagrelor than after clopidogrel in patients aged ≥75 years (adjusted HR 6.14, 95% CI 1.40 to 26.90) but not in patients aged <75 years (adjusted HR 0.93, 95% CI 0.50 to 1.73). The incidences of clinically significant bleeding were significantly higher after ticagrelor than after clopidogrel in men (adjusted HR 2.69, 95% CI 1.38 to 5.24) but not in women (adjusted HR 1.49, 95% CI 0.64 to 3.46). The adjusted risks of MACEs after ticagrelor or clopidogrel were not significantly different between men and women. In conclusion, there were substantial age- and gender-related differences in bleeding and ischemic outcomes after ticagrelor or clopidogrel in Korean patients with acute coronary syndrome. Clinical Trial Registration: URL: https://www.clinicaltrials.gov Unique identifier: NCT02094963.

Clinical Trial Technologies for Improving Equity and Inclusion in Cardiovascular Clinical Research

Approximately one-third of clinical trials fail to meet their recruitment goals, which can cause costly delays to sponsors and compromise the scientific integrity and generalizability of a trial. Inadequate recruitment and retention of patient groups who have the disease under investigation may produce insufficient medical knowledge about the therapeutic effects of drugs or products for the population at large. It is essential to address these issues to ensure that certain groups are not unduly subjected to disproportionate risks or denied the benefits of research. This commentary will present opportunities for clinical trialists to use emerging technologies and decentralized approaches to improve clinical trial recruitment, mitigate disparities, and improve individual and population-level outcomes within cardiovascular medicine.

Clinical and psychological characteristics of patients with ischemia and non-obstructive coronary arteries (INOCA) and obstructive coronary artery disease

Study objective

Ischemia with non-obstructive coronary arteries (INOCA) is caused by vascular dysfunctions and predominantly seen in women. For better recognition and prevention more insight is needed on risk factors and well-being. We aimed to explore differences in psychological distress, quality of life, risk factors, and medication use between women with INOCA and obstructive coronary artery disease (CAD).

Methods

Patients from two separate studies (n = 373, 57 % women) completed a questionnaire assessing psychological and clinical factors. Analyses were performed for women only who were categorized into three groups: non-ischemic chest pain (n = 115), INOCA (n = 68), and obstructive CAD (n = 30). Secondary analyses were performed for men only, and sex differences within INOCA patients were explored.

Results and conclusion

Compared to obstructive CAD patients, INOCA patients reported better physical functioning (p = 0.041). Furthermore, INOCA patients had less often hypercholesterolemia (p < 0.001), were less often active smokers (p = 0.062), had a lower mean BMI (p = 0.022), and reported more often a familial history of CAD (p = 0.004). Patients with INOCA used antithrombotic, cholesterol lowering medications, and beta-blockers less often than patients with obstructive CAD. No differences between patients with INOCA and obstructive CAD were found for psychological distress, well-being, and for women-specific risk factors. The results suggest that women with INOCA experience similar levels of psychological distress and seem to have different risk factor profiles and are less optimally treated as compared to obstructive CAD patients. Further research on risk factors is needed for better prevention and treatment.

The Impact of Sex and Gender in Medicine and Pharmacology

Sex and gender play a pivotal role in health and disease. Differences can be identified in symptoms, biomarkers, lifetime experiences of diseases, incidence, prevalence, therapeutic options, health-related behavior, and resiliency. However, awareness of sex and gender differences in medicine is still limited. Systematic implementation of sex and gender-sensitive research is not yet the norm, resulting in gaps in evidence especially in the diagnosis and treatment of diseases in women. For decades research has predominantly included male persons and animals, leading to a lack of information about symptoms in female individuals or the classification of their symptoms as "atypical". Currently, the inclusion of female participants in clinical marketing access trials is mandatory. However, this does not automatically translate into sex-disaggregated analyses potentially limiting the discovery of sex-specific targeted therapeutic schemes. Consistent consideration of sex and gender in planning, conducting, analyzing, and dissemination of pharmacological research projects is an important prerequisite for closing the gender data gap. Targeted implementation strategies might help to include sex and gender aspects in different parts of the health system and thereby support the improvement of health care for all patients. Health economic aspects could be a further drive for the implementation of sex- and gender-sensitive medicine.The current chapter focuses on the role of sex and gender in biomedical research and, consequently, their potential role in pharmacology. We will explore the commonly used terminology in the field, the historical development of sex and gender-sensitive medicine (SGSM), the relevance of sex and gender to research and clinical practice and conclude with an outlook on future developments in the field.

Adverse Reaction of Acupuncture and Antihypertensive Drugs for Treatment of Essential hypertension: A Protocol for Bayesian Network Meta-Analysis

Background

Hypertension, as a high risk factor of cardiovascular disease, has led to a significant upward trend in the population and incidence of the disease. Hypertension patients need to take antihypertensive drugs for life, and therefore people gradually pay more attention to the adverse reactions of antihypertensive drugs. This study protocol outlines a plan to assess the adverse reaction of the different antihypertensive drugs and acupuncture in order for clinical application.

Objective

To compare the side effects of different antihypertensive drugs and acupuncture in the treatment of hypertension.

Methods

and analysis. We will search the databases containing CNKI, Wan-Fang database, Chinese Scientific Journal Database(VIP), PubMed, Cochrane, and Embase, and randomized controlled trials (RCTs) of commonly used antihypertensive drugs or acupuncture for primary hypertension will be obtained. Then, Stata14.0 and Gemtc will be used to assess the statistics. Ethics and dissemination. Since no personal patient consent will be required in the study, there is no ethical approval. The results of this reporting will be submitted to a peer-reviewed publication. PROSPERO registration number: CRD42020152703.

Cardiac medication use in patients with suspected ischaemia without obstructive coronary arteries: sex differences and psychological distress

BACKGROUND

Ischaemia without obstructive coronary arteries (INOCA) is more prevalent in women and associated with psychological distress. Pharmacological treatment goals are angina relief and cardiovascular risk management. The present study aims to examine sex differences in cardiac and non-cardiac medication use, as well as medication and sex differences related to consistent psychological distress in patients with suspected INOCA.

DESIGN

A TweeSteden mild stenosis observational cohort study in patients with suspected INOCA as detected by ischaemic reason for referral and non-obstructive arteries based on coronary angiography or computed tomography.

METHODS

Medication documented in the hospital records of 488 patients (53% women) was coded as angina relief medication, blood-pressure-lowering medication, antithrombotics, statins, and non-cardiac medication, using the Anatomical Therapeutic Chemical code. Depressive symptoms and anxiety were recoded as 'consistent distress' (above the cut-off score for depression and anxiety on validated questionnaires), 'inconsistent distress' (above the cut-off for depression or anxiety) or 'no distress' (below the cut-off).

RESULTS

No sex differences were observed in cardiac medication use. Women used anxiolytic benzodiazepines more often (12% vs 4%, p = 0.002) compared to men. Consistent distress was more prevalent in women (22% vs 15%, p = 0.004) and was related to the use of more angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and diuretics in women and to calcium antagonist use as well as lower adherence levels in men. Women who reported chest pain more often received angina relief medication and blood-pressure-lowering medication than men.

CONCLUSION

No sex differences were observed in cardiac medication use in patients with suspected INOCA. Psychological distress may reflect hypertension and subsequent medication use in women, and experiencing chest pain and subsequent medication use in men.

Efficacy and Pharmacological Appropriateness of Cinnarizine and Dimenhydrinate in the Treatment of Vertigo and Related Symptoms

Vertigo is not itself a disease, but rather a symptom of various syndromes and disorders that jeopardize balance function, which is essential for daily activities. It is an abnormal sensation of motion that usually occurs in the absence of motion, or when a motion is sensed inaccurately. Due to the complexity of the etiopathogenesis of vertigo, many pharmacological treatments have been tested for efficacy on vertigo. Among these drugs, cinnarizine, usually given together with dimenhydrinate, appears to be the first-line pharmacotherapy for the management of vertigo and inner ear disorders. Based on these considerations, the present non-interventional study aimed to investigate the clinical efficacy and tolerability of a fixed combination of cinnarizine (20 mg) and dimenhydrinate (40 mg) in patients suffering from vertigo-related symptoms. To this end, we enrolled 120 adults-70 males, and 50 females-with an average age of 64 years. Before beginning pharmacological treatment, all patients were screened for the intensity of vertigo, dizziness, and concomitant symptoms through the Visual Scale of Dizziness Disorders and Dizziness Handicap Inventory scales. At the end of the anamnestic evaluation, patients received the fixed-dose combination of cinnarizine (20 mg) plus dimenhydrinate (40 mg) 3 times daily, for 60 days. The results of this study provide further insight regarding the efficacy of the fixed combination when used to reduce symptoms of vestibular vertigo of central and/or peripheral origin, after both the 15- and 60-day therapies. Independent of the type of vertigo, the fixed combination was able to reduce dizziness- and vertigo-associated symptoms in more than 75% of all patients treated, starting from 15 days of therapy, and improving 60 days after starting the therapy. Interestingly, we also found differences between male and female patients in the framework of the pharmacological effects of therapy. This study provides further details concerning the therapeutic efficacy of the fixed combination of cinnarizine and dimenhydrinate, and also focuses attention on the possibility that these drugs could act in a gender-specific manner, paving the way for further research.

Sex Differences in Infective Endocarditis

BACKGROUND

The impact of sex on the presentation, etiology, and outcomes of infective endocarditis (IE) has not been adequately studied. The aim of the present research was to analyze the impact of sex on the presentation, etiology, and outcomes of IE.

METHODS

We performed a retrospective study of 214 adult patients (131 male and 83 female) with IE. All cases of IE were reviewed by two investigators- both senior physicians in internal medicine. Two groups of patients were compared: male and female patients with IE. The primary outcome was in-hospital mortality.

RESULTS

We found significant differences in etiologic factors of IE in male and female patients. Microbiologic etiology differences between male and female groups of patients were in coagulase negative staphylococcus (15.0% in male vs 3.8% in female groups, P = 0.011), and culture negative endocarditis (8.7% in male vs 23.8% in female groups, P = 0.004). We did not find a difference in the primary outcome between the two groups; however, all-cause mortality was significantly higher in the female group as compared to the male group (26 [31.3] vs 22 [16.8], P = 0.018).

CONCLUSIONS

We found that sex may have important role in both the microbial profile and the patient's outcome with IE.

Efficacy and Safety of High Potent P2Y12 Inhibitors Prasugrel and Ticagrelor in Patients With Coronary Heart Disease Treated With Dual Antiplatelet Therapy: A Sex-Specific Systematic Review and Meta-Analysis

Background

Sex differences in efficacy and safety of dual antiplatelet therapy remain uncertain because of the underrepresentation of women in cardiovascular trials. The aim of this study was to perform a sex‐specific analysis of the pooled efficacy and safety data of clinical trials comparing a high potent P2Y₁₂ inhibitor+aspirin with clopidogrel+aspirin in patients with acute coronary syndrome.

Methods and Results

A systematic literature search was performed. Randomized clinical trials that compared patients following percutaneous coronary intervention/acute coronary syndrome who were taking high potent P2Y₁₂ inhibitors+aspirin versus clopidogrel+aspirin were selected. Random effects estimates were calculated and relative risks with 95% CIs on efficacy and safety end points were determined per sex. We included 6 randomized clinical trials comparing prasugrel/ticagrelor versus clopidogrel in 43 990 patients (13 030 women), with a median follow‐up time of 1.06 years. Women and men had similar relative risk (RR) reduction for major cardiovascular events (women: RR, 0.89 [95% CI, 0.80–1.00; men: RR, 0.84 [95% CI, 0.79–0.91) (P for interaction=0.39). Regarding safety, women and men had similar risk of major bleeding by high‐potency dual antiplatelet therapy (RR, 1.18 [95% CI, 0.98–1.41] versus RR, 1.03 [95% CI, 0.93–1.14]) (P for interaction=0.20).

Conclusions

The small and statistically insignificant difference in efficacy and safety estimates of high‐potency dual antiplatelet therapy between women and men following percutaneous coronary intervention/acute coronary syndrome do not justify differential dual antiplatelet therapy treatment for both sexes.

Sex differences in spontaneous reports on adverse drug events for common antihypertensive drugs

Purpose

To explore sex differences in spontaneously reported adverse drug events (ADEs) for antihypertensives in routine care.

Methods

A cross sectional analysis combining number of reports from the national pharmacovigilance database with data from the Swedish Prescribed Drug Register, from 2005 to 2012 for ACE inhibitors (ACE-I) and angiotensin receptor blockers (ARB), with or without thiazide, diuretics (thiazides, potassium-sparing agents, sulfonamides, aldosterone antagonists), selective betablockers, and dihydropyridine calcium-channel-blockers (DHPs). The total number of reports was adjusted to exposed patients and dispensed DDDs among women and men. Dose exposures, co-medications, and co-prescriptions were also analyzed.

Results

In women, a higher prevalence of ADE-reports was seen in ACE-I (odds ratio, OR 1.21; 95% CI 1.09–1.35), ACE-I-combinations (OR 1.61; 1.44–1.79), ARB-combinations (OR 2.12; 1.47–3.06), thiazides (OR 1.78; 1.33–2.39), diuretics and potassium-sparing agents (OR 1.62; 1.22–2.17), and DHPs (OR 1.40; 1.17–1.67), with a potential linkage to dose exposure. For aldosterone antagonists, we observed a higher prevalence of ADE reports in men (OR 0.75; 0.59–0.97) but without any sex difference in dose exposure.

Conclusions

This ecological study of reported ADEs showed a higher prevalence of reports in women in six out of ten groups of antihypertensive drugs, and this may potentially be linked to dose exposure. Aldosterone antagonists was the only group with a higher prevalence of ADE-reports in men with a similar dose exposure between women and men.

Electronic supplementary material

The online version of this article (10.1007/s00228-018-2480-y) contains supplementary material, which is available to authorized users.

Sex-Specific Characteristics of the Microcirculation

The requirements of metabolizing tissue are both continuous and variable; accordingly, the microvasculature serving that tissue must be similarly dynamic. Just as it is recognized that males and females of the same species have differing metabolic requirements, is it not likely that the microvasculature serving these tissues will differ by sex? This section focusing on the constituents of the microcirculation identifies what is known presently about the role sex plays in matching metabolic demand with microvascular function and areas requiring additional study. Many of the identified sex differences are subtle and easily ignored. In the aggregate, though, they can profoundly alter phenotype, especially under stressful conditions including pregnancy, exercise, and disease states ranging from diabetes to heart failure. Although the features presently identified to "have sex" range from differences in growth, morphology, protein expression, and intracellular signaling, males and females alike achieve homeostasis, likely by different means. Studies of microvascular sexual dimorphism are also identifying age as an independent but interacting factor requiring additional attention. Overall, attempting to ignore either sex and/or age is inappropriate and will prevent the design and implementation of appropriate interventions to present, ameliorate, or correct microvascular dysfunction.

En route to precision medicine through the integration of biological sex into pharmacogenomics

Frequently, pharmacomechanisms are not fully elucidated. Therefore, drug use is linked to an elevated interindividual diversity of effects, whether therapeutic or adverse, and the role of biological sex has as yet unrecognized and underestimated consequences. A pharmacogenomic approach could contribute towards the development of an adapted therapy for each male and female patient, considering also other fundamental features, such as age and ethnicity. This would represent a crucial step towards precision medicine and could be translated into clinical routine. In the present review, we consider recent results from pharmacogenomics and the role of sex in studies that are relevant to cardiovascular therapy. We focus on genome-wide analyses, because they have obvious advantages compared with targeted single-candidate gene studies. For instance, genome-wide approaches do not necessarily depend on prior knowledge of precise molecular mechanisms of drug action. Such studies can lead to findings that can be classified into three categories: first, effects occurring in the pharmacokinetic properties of the drug, e.g. through metabolic and transporter differences; second, a pharmacodynamic or drug target-related effect; and last diverse adverse effects. We conclude that the interaction of sex with genetic determinants of drug response has barely been tested in large, unbiased, pharmacogenomic studies. We put forward the theory that, to contribute towards the realization of precision medicine, it will be necessary to incorporate sex into pharmacogenomics.

Gender difference in the response to valsartan/amlodipine single-pill combination in essential hypertension (China Status II): An observational study

BACKGROUND

The China STATUS II is a prospective, multicentre, open-label, post-marketing, observational study including Chinese adults (aged ⩾ 18 years) with essential hypertension who were prescribed once-daily valsartan/amlodipine (Val/Aml 80/5 mg) single-pill combination. In order to examine gender differences in treatment response to Val/Aml, we further analysed data from the China STATUS II study.

METHODS

A total of 11,312 patients (6456 (57%) men and 4856 (43%) women) received the Val/Aml treatment for 8 weeks. After the treatment, we compared the proportion of patients not achieving the target systolic blood pressure (SBP: < 140 mm Hg) or diastolic blood pressure (DBP: < 90 mm Hg) in different age groups (by Fisher exact probability test) and estimated the changes in blood pressure (BP) according to age and gender, using a mixed model.

RESULTS

At enrolment, mean SBP was higher in the female versus the male patients (160.0 ± 12.71 versus 159.3 ± 12.31 mm Hg; p = 0.003), whereas the mean DBP was higher in the male versus the female patients (96.4 ± 10.65 versus 94.5 ± 10.72 mm Hg; p < 0.001). The overall proportion of women not achieving the target BP was less than that of men (57.41% versus 59.59%; p < 0.05) at 4 weeks and (22.22% versus 23.78%; p < 0.05) at 8 weeks after the Val/Aml treatment. Among both men and women, the proportion of patients not achieving the target SBP increased with age; however, the proportion not achieving the target DBP decreased with age. The mixed-model analysis showed that the changes in SBP were closely related to gender, indicating that the SBP-lowering effect after Val/Aml treatment might be better in women. In addition, the changes in DBP were closely related to age.

CONCLUSIONS

Gender might be a factor for consideration in the decision-making process of individualised antihypertensive therapy, in the future.

Gender medicine: a task for the third millennium

Gender-specific medicine is the study of how diseases differ between men and women in terms of prevention, clinical signs, therapeutic approach, prognosis, psychological and social impact. It is a neglected dimension of medicine. In this review we like to point out some major issues in five enormous fields of medicine: cardiovascular diseases (CVDs), pharmacology, oncology, liver diseases and osteoporosis. CVDs have been studied in the last decades mainly in men, but they are the first cause of mortality and disability in women. Risk factors for CVD have different impacts in men and women; clinical manifestations of CVD and the influence of drugs on CVD have lot of gender differences. Sex-related differences in pharmacokinetics and pharmacodynamics are also emerging. These differences have obvious relevance to the efficacy and side effect profiles of various medications in the two sexes. This evidence should be considered for drug development as well as before starting any therapy. Gender disparity in cancer incidence, aggressiveness and prognosis has been observed for a variety of cancers and, even if partially known, is underestimated in clinical practice for the treatment of the major types of cancer. It is necessary to systematize and encode all the known data for each type of tumor on gender differences, to identify where this variable has to be considered for the purposes of the prognosis, the choice of treatment and possible toxicity. Clinical data suggest that men and women exhibit differences regarding the epidemiology and the progression of certain liver diseases, i.e., autoimmune conditions, genetic hemochromatosis, non-alcoholic steatohepatitis and chronic hepatitis C. Numerous hypotheses have been formulated to justify this sex imbalance including sex hormones, reproductive and genetic factors. Nevertheless, none of these hypothesis has thus far gathered enough convincing evidence and in most cases the evidence is conflicting. Osteoporosis is an important public health problem both in women and men. On the whole, far more epidemiologic, diagnostic and therapeutic studies have been carried out in women than in men. In clinical practice, if this disease remains underestimated in women, patients' and physicians' awareness is even lower for male osteoporosis, for which diagnostic and therapeutic strategies are at present less defined. In conclusion this review emphasizes the urgency of basic science and clinical research to increase our understanding of the gender differences of diseases.

Gender and polypharmacotherapy in the elderly: a clinical challenge

Polypharmacotherapy is a major concern in the elderly and especially in older women after the age of 80. It results from the intake of prescription and non-prescription drugs, being often a problem of evidence-based therapy. Besides the fact that women live longer than men and outnumber them, reasons for polypharmacy in women are diverse and include a different attitude towards intake of drugs between men and women, the propensity of women to rather see a physician and talk about their problems, the load of family responsibility as women are the main caregivers within a family, the influence of physician sex on patient care, the level of education, social deprivation and self-rated health. Women are more often prescribed potentially inappropriate medication and more often become victims of adverse drug reactions. This is not only due to the number and quality of drugs prescribed but also to differences in pharmacokinetics and - dynamics which make them more vulnerable to drug exposure. Thus, inappropriate prescribing contributes to hospitalization, poor quality of life, costs, compliance issues and poor outcomes. More preclinical and clinical studies with elderly patients and especially elderly women are needed to study the underlying mechanisms of the pharmacologic differences and obtain more insight into the difference in risk between men and women. Attention to prescribing of medications, consistent review of medication lists, and reevaluation of indications and outcomes of prescribing are essential to ensure that drugs are used appropriately in elderly women, polypharmacy is minimized and safety for patients is maximized.

Gender differences in chemical carcinogenesis in National Toxicology Program 2-year bioassays

Differences in cancer incidences between men and women are often explained by either differences in environmental exposures or by influences of sex hormones. However, there are few studies on intrinsic gender differences in susceptibility to chemical carcinogens. We have analyzed the National Toxicology Program (NTP) database for sex differences in rat responses to chemical carcinogens. We found that the odds that male rat bioassays were assigned a higher level of evidence than female rat bioassays was 1.69 (p < .001). Of 278 carcinogenic chemicals in the database, 201 (72%) exhibited statistical gender differences (p ≤ .05) in at least one nonreproductive organ. One hundred thirty of these 201 chemicals induced gender-specific tumors in male rats and 59 in female rats. Sixty-eight chemicals induced tumors in males but no tumors in females. Less than one third (i.e., 19 chemicals) induced tumors in females but not males. Male-specific tumors included pancreatic and skin tumors, and female-specific tumors included lung tumors. For some tumor sites, these differences in gender susceptibility can be associated with literature data on sex hormone receptor expression. In conclusion, gender-specific tumors were common. The male dominance is in line with recent human data, and the male susceptibility to carcinogens should be further studied.

Sex differences in drug effects: interaction with sex hormones in adult life

In recent years, it has become clear that women and men may differ for drug response. Also, there is an increasing recognition on the role of sex hormones on pharmacokinetics and pharmacodynamics as mechanism accounting for sex differences in drug effects.In women, the phases of menstrual cycle, of reproductive life and fluctuations in the concentrations of sexual steroids on pharmacokinetics and pharmacodynamics must be considered. Furthermore, the use of oral contraceptives or hormonal replacement therapy, the sex hormone-related changes in total body water or in the amount of fat influence the overall effect of drugs.On the contrary, the influence of androgens on drug effects is minimal because of the even plasma levels of these hormones in adult males.Nevertheless, since women have been scarcely included in the early phases of clinical trials, the results obtained in men have been often translated to women and their exact response to drugs is still not well known.The available evidence suggests that sex hormones influence drug absorption, distribution, metabolism, pharmacodynamics, and adverse effects. For instance, many cardiovascular drugs are metabolized by enzymes of the cytochrome P450 mono-oxygenases system, which is more expressed in females than in males, showing sex differences in drug response.Upcoming pharmacological research should aim to further clarify the influence of sex hormones on drug effects and, for this purpose, to increase the number of women enrolled in all phases of clinical trials. An evidence-based pharmacotherapy in women is therefore auspicable for women's health.

Time trends in STEMI--improved treatment and outcome but still a gender gap: a prospective observational cohort study from the SWEDEHEART register

OBJECTIVE

In ST elevation myocardial infarction women received less evidence-based medicine and had worse outcome during the fibrinolytic era. With the shift to primary percutaneous coronary intervention (pPCI) as preferred reperfusion strategy, the authors aimed to investigate whether these gender differences has diminished.

DESIGN, SETTING AND PARTICIPANTS

Cohort study including consecutive ST elevation myocardial infarction patients registered 1998-2000 (n=15 697) and 2004-2006 (n=14 380) in the Register of Information and Knowledge about Swedish Heart Intensive care Admissions.

OUTCOME MEASURES

1. Use of evidence-based medicine such as reperfusion therapy (pPCI or fibrinolysis) and evidence-based drugs at discharge. 2. Inhospital and 1-year mortality.

RESULTS

Of those who got reperfusion therapy, pPCI was the choice in 9% in the early period compared with 68% in the late period. In the early period, reperfusion therapy was given to 63% of women versus 71% of men, p<0.001. Corresponding figures in the late period were 64% vs 75%, p<0.001. After multivariable adjustments, the ORs (women vs men) were 0.86 (95% CI 0.78 to 0.94) in the early and 0.80 (95% CI 0.73 to 0.89) in the late period. As regards evidence-based secondary preventive drugs at discharge in hospital survivors (platelet inhibitors, statins, ACE inhibitors/angiotensin receptor blockers and β-blockers), there were small gender differences in the early period. In the late period, women had 14%-25% less chance of receiving these drugs, OR 0.75 (95% CI 0.68 to 0.81) through 0.86 (95% CI 0.73 to 1.00). In both periods, multivariable-adjusted inhospital mortality was higher in women, OR 1.18 (95% CI 1.02 to 1.36) and 1.21 (1.00 to 1.46). One-year mortality was gender equal, HR 0.95 (95% CI 0.87 to 1.05) and 0.96 (0.86 to 1.08), after adding evidence-based medicine to the multivariable adjustments.

CONCLUSION

In spite of an intense gender debate, focus on guideline adherence and the change in reperfusion strategy, the last decade gender differences in use of reperfusion therapy and evidence-based therapy at discharge did not decline during the study period, rather the opposite. Moreover, higher mortality in women persisted.

Breakout session: Gender and ethnic disparities in pain management

BACKGROUND

Pain management is a complex and evolving topic. Treatment of pain must account for biochemical as well as social and economic factors. Sex, gender, and ethnic differences exist in the pathophysiology, diagnosis, and provision of care for patients with pain.

QUESTIONS/PURPOSES

We sought to identify the sex, gender, and ethnic disparities leading to care inequalities with respect to pain management. Our purposes were to (1) clarify the state of where we are now, (2) outline ways to approach where we need to go, and (3) generate solutions for how we get there. WHERE ARE WE NOW?: Studies are beginning to uncover the biologic mechanisms underlying the pain response in sex, gender, and ethnic subgroups. Patient characteristics that increase the risk of postoperative pain are being identified. WHERE DO WE NEED TO GO?: Much work needs to be done in medical education with respect to sex, gender, and ethnic disparities in pain management. Research efforts must better describe differences in physiology of pain, incidence of pain, coping strategies, patient-doctor relationships, and gender/ethnic-specific modes of care for the patient with pain. HOW DO WE GET THERE?: Future work will involve combined efforts with pain/anesthesia specialty societies, developing a disparities and pain management curriculum for medical providers, endorsing health literacy, performing high-quality Level I/II research, and exploring systems processes in pain management in the acute hospital setting.

Analysis of sex and gender-specific research reveals a common increase in publications and marked differences between disciplines

BACKGROUND

The incorporation of sex and gender-specific analysis in medical research is increasing due to pressure from public agencies, funding bodies, and the clinical and research community. However, generations of knowledge and publication trends in this discipline are currently spread over distinct specialties and are difficult to analyze comparatively.

METHODS

Using a text-mining approach, we have analysed sex and gender aspects in research within nine clinical subspecialties--Cardiology, Pulmonology, Nephrology, Endocrinology, Gastroenterology, Haematology, Oncology, Rheumatology, Neurology--using six paradigmatic diseases in each one. Articles have been classified into five pre-determined research categories--Epidemiology, Pathophysiology, Clinical research, Management and Outcomes. Additional information has been collected on the type of study (human/animal) and the number of subjects included. Of the 8,836 articles initially retrieved, 3,466 (39%) included sex and gender-specific research and have been further analysed.

RESULTS

Literature incorporating sex/gender analysis increased over time and displays a stronger trend if compared to overall publication increase. All disciplines, but cardiology (22%), demonstrated an underrepresentation of research about gender differences in management, which ranges from 3 to 14%. While the use of animal models for identification of sex differences in basic research varies greatly among disciplines, studies involving human subjects are frequently conducted in large cohorts with more than 1,000 patients (24% of all human studies).

CONCLUSIONS

Heterogeneity characterizes sex and gender-specific research. Although large cohorts are often analysed, sex and gender differences in clinical management are insufficiently investigated leading to potential inequalities in health provision and outcomes.