Macrolides, Digoxin Toxicity and the Risk of Sudden Death: A Population-Based Study

Quality of reporting of drug exposure in pharmacoepidemiological studies

Purpose

Exposure definitions vary across pharmacoepidemiological studies. Therefore, transparent reporting of exposure definitions is important for interpretation of published study results. We aimed to assess the quality of reporting of exposure to identify where improvement may be needed.

Method

We systematically reviewed observational pharmacoepidemiological studies that used routinely collected health data, published in 2017 in six pharmacoepidemiological journals. Reporting of exposure was scored using 11 items of the ISPE‐ISPOR guideline on reporting of pharmacoepidemiological studies.

Results

Of the 91 studies included, all studies reported the type of exposure (100%), while most reported the exposure risk window (85%) and the exposure assessment window (98%). Operationalization of the exposure window was described infrequently: 16% (14/90) of the studies explicitly reported the presence or absence of an induction period if applicable, 11% (5/47), and 35% (17/49) reported how stockpiling and gaps between exposure episodes were handled, respectively, and 35% (17/49) explicitly mentioned the exposure extension. Switching/add‐on was reported in 62% (50/81). How switching between drugs was dealt with and specific drug codes were reported in 52 (57%) and 24 (26%) studies, respectively.

Conclusion

Publications of pharmacoepidemiological studies frequently reported the type of exposure, the exposure risk window, and the exposure assessment window. However, more details on exposure assessment are needed, especially when it concerns the operationalization of the exposure risk window (eg, the presence or absence of an induction period or exposure extension, handling of stockpiling and gaps, and specific codes), to allow for correct interpretation, reproducibility, and assessment of validity.

Evaluation of the Cardiac Effects of a Water-Soluble Lectin (Wsmol) from Moringa Oleifera Seeds

Fundsamento

As sementes de Moringa oleifera , que são utilizadas para clarificação de água, contêm uma lectina chamada WSMoL que tem mostrado atividade antibacteriana e imunomoduladora in vitro . Devido ao seu valor nutritivo e potencial terapêutico, as folhas e as sementes dessa árvore são consumidas em algumas comunidades. Algumas lectinas de plantas não são tóxicas para mamíferos, mas tem sido relatado que outras são prejudiciais quando ingeridas ou administradas por outros meios.

Objetivo

Como um dos passos necessários para determinar a segurança de WSMoL, nós avaliamos os possíveis efeitos cardiotóxicos desta proteína purificada.

Métodos

Durante 21 dias consecutivos, a WSMoL foi administrada a camundongos por gavagem. Foram investigadas as funções eletrofisiológicas, mecânicas e metabólicas in vivo e ex vivo por meio de registros eletrocardiográficos, ressonância magnética nuclear e respirometria de alta resolução.

Resultados

O tratamento com WSMoL não induziu alterações nos níveis de glicose no sangue ou peso corporal em comparação com o grupo controle. Adicionalmente, as relações peso cardíaco/peso corporal e peso cardíaco/comprimento tibial estavam semelhantes em ambos os grupos. A ingestão de lectina também não modificou a tolerância à glicose ou resistência à insulina. Não foram observadas alterações nos parâmetros eletrocardiográficos ou na duração do potencial de ação cardíaco. Os corações dos camundongos dos grupos controle e WSMoL mostraram função ventricular esquerda preservada. Além disso, a WSMoL não induziu alterações na função mitocondrial (em todos os casos, p > 0,05).

Conclusões

A administração de WSMoL demonstrou ter um perfil de segurança cardíaca. Estes resultados contribuem à avaliação de segurança do uso de sementes de M. oleifera para tratar água, visto que essa lectina está presente na preparação empregada por algumas populações com esse fim. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Association Between Palliative Care and Death at Home in Adults With Heart Failure

Background Palliative care is associated with improved symptom control and quality of life in people with heart failure. There is conflicting evidence as to whether it is associated with a greater likelihood of death at home in this population. The objective of this study was to describe the delivery of newly initiated palliative care services in adults who die with heart failure and measure the association between receipt of palliative care and death at home compared with those who did not receive palliative care. Methods and Results We performed a population-based cohort study using linked health administrative data in Ontario, Canada of 74 986 community-dwelling adults with heart failure who died between 2010 and 2015. Seventy-five percent of community-dwelling adults with heart failure died in a hospital. Patients who received any palliative care were twice as likely to die at home compared with those who did not receive it (adjusted odds ratio 2.12 [95% CI, 2.03-2.20]; P<0.01). Delivery of home-based palliative care had a higher association with death at home (adjusted odds ratio 11.88 [95% CI, 9.34-15.11]; P<0.01), as did delivery during transitions of care between inpatient and outpatient care settings (adjusted odds ratio 8.12 [95% CI, 6.41-10.27]; P<0.01). Palliative care was most commonly initiated late in the course of a person's disease (≤30 days before death, 45.2% of subjects) and led by nonspecialist palliative care physicians 61% of the time. Conclusions Most adults with heart failure die in a hospital. Providing palliative care near the end-of-life was associated with an increased likelihood of dying at home. These findings suggest that scaling existing palliative care programs to increase access may improve end-of-life care in people dying with chronic noncancer illness.

Association between Physician Intensity of Antibiotic Prescribing and the Prescription of Benzodiazepines, Opioids and Proton-Pump Inhibitors to Nursing Home Residents: a Population-Based Observational Study

BACKGROUND

Prescribing patterns for episodic medications, such as antibiotics, might make useful surrogate measures of a physician's overall prescribing practice because use is common, and variation exists across prescribers. However, the extent to which a physician's current antibiotic prescribing practices are associated with the rate of prescription of other potentially harmful medications remains unknown.

OBJECTIVE

To examine the association between a physician's rate of antibiotic prescribing and their prescribing rate of benzodiazepines, opioids and proton-pump inhibitors in older adults.

DESIGN

Population-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients.

PARTICIPANTS

1926 physicians who provided care among 128,979 physician-patient pairs in 2015.

MAIN MEASURES

Likelihood of prescribing a benzodiazepine, opioid or proton-pump inhibitor between low-, average- and high-intensity antibiotic prescribers, adjusted for patient characteristics.

KEY RESULTS

Compared with average-intensity antibiotic prescribers, high-intensity prescribers had an increased likelihood of prescribing a benzodiazepine (odds ratio 1.21 [95% CI, 1.11-1.32]), an opioid (odds ratio 1.28 [95% CI, 1.17-1.39]) or a proton-pump inhibitor (odds ratio 1.38 [95% CI, 1.27-1.51]]. High-intensity antibiotic prescribers were more likely to be high prescribers of all three medications (odds ratio 6.24 [95% CI, 2.90-13.39]) and also more likely to initiate all three medications, compared with average-intensity prescribers.

CONCLUSIONS

The intensity of a physician's episodic antibiotic prescribing was significantly associated with the likelihood of new and continued prescribing of opioids, benzodiazepines and proton-pump inhibitors in nursing homes. Patterns of episodic prescribing may be a useful mechanism to target physician-level interventions to optimize general prescribing behaviors, instead of prescribing behaviors for single medications.

Systematic Review, Meta-analysis, and Network Meta-analysis of the Cardiovascular Safety of Macrolides

Studies reporting an increased risk for cardiac toxicities with macrolide antibiotics have raised concern regarding their cardiovascular safety. We sought to assess the cardiac safety of macrolide antibiotics as a class and of the individual agents by conducting a systematic review and network meta-analysis. Medline, Embase, and the Cochrane Library were searched up to February 2018 for studies reporting on cardiovascular outcomes with macrolides. We followed the PRISMA 2009 guidelines for data selection and extraction. Outcomes were pooled using random-effects models and odds ratios (OR), and 95% confidence intervals (CI) were calculated for arrhythmia, cardiovascular death, and myocardial infarction (MI). A total of 33 studies and data on 22,601,032 subjects were retrieved and included in the current meta-analyses. Macrolide use was not associated with the risk of arrhythmia or cardiovascular mortality. In the primary analysis, macrolide use was associated with a small but statistically significant 15% increase in risk for MI (OR = 1.15 [95% CI, 1.01 to 1.30]). In indirect network meta-analysis, erythromycin and clarithromycin were ranked considerably more likely to be associated with a higher risk for MI and significantly associated with increased risk of MI compared to azithromycin (OR = 1.58 [95% CI, 1.18 to 2.11] and OR = 1.41 [95% CI, 1.11 to 1.81], respectively). Our findings indicate that macrolide antibiotics as a group are associated with a significant risk for MI but not for arrhythmia and cardiovascular mortality. Among the macrolides, erythromycin and clarithromycin were associated with a greater risk of MI. However, it is possible that the association between macrolide use and risk of MI is the result of residual confounding.