Vulvo-vaginal candidiasis associated with acitretin

Drug eruptions and the vulva

Drug reactions affecting the vulva are understudied and underreported, with some having the potential to cause serious morbidity through long-term sequelae. We conducted a literature review to investigate the current evidence about vulval drug eruptions. We aimed to establish the extent of drug reactions affecting the vulva, identify the common culprit drugs, and review current evidence and guidelines regarding their management. The vulval involvement seen in Steven-Johnson syndrome, toxic epidermal necrolysis and fixed drug eruption forms the focus of this review, but we also summarize the current evidence regarding less common reactions.

Prescribing Cascades with Recommendations to Prevent or Reverse Them: A Systematic Review

BACKGROUND

To reduce prescribing cascades occurring in clinical practice, healthcare providers require information on the prescribing cascades they can recognize and prevent.

OBJECTIVE

This systematic review aims to provide an overview of prescribing cascades, including dose-dependency information and recommendations that healthcare providers can use to prevent or reverse them.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Relevant literature was identified through searches in OVID MEDLINE, OVID Embase, OVID CINAHL, and Cochrane. Additionally, Web of Science and Scopus were consulted to analyze reference lists and citations. Publications in English were included if they analyzed the occurrence of prescribing cascades. Prescribing cascades were included if at least one study demonstrated a significant association and were excluded when the adverse drug reaction could not be confirmed in the Summary of Product Characteristics. Two reviewers independently extracted and grouped similar prescribing cascades. Descriptive summaries were provided regarding dose-dependency analyses and recommendations to prevent or reverse these prescribing cascades.

RESULTS

A total of 95 publications were included, resulting in 115 prescribing cascades with confirmed adverse drug reactions for which at least one significant association was found. For 52 of these prescribing cascades, information regarding dose dependency or recommendations to prevent or reverse prescribing cascades was found. Dose dependency was analyzed and confirmed for 12 prescribing cascades. For example, antipsychotics that may cause extrapyramidal syndrome followed by anti-parkinson drugs. Recommendations focused on dosage lowering, discontinuing medication, and medication switching. Explicit recommendations regarding alternative options were given for three prescribing cascades. One example was switching to ondansetron or granisetron when extrapyramidal syndrome is experienced using metoclopramide.

CONCLUSIONS

In total, 115 prescribing cascades were identified and an overview of 52 of them was generated for which recommendations to prevent or reverse them were provided. Nonetheless, information regarding alternative options for managing prescribing cascades was scarce.

Hot weather and death related to acute cocaine, opioid and amphetamine toxicity in British Columbia, Canada: a time-stratified case-crossover study

BACKGROUND

Previous research has shown that cocaine-associated deaths occur more frequently in hot weather, which has not been described for other illicit drugs or combinations of drugs. The study objective was to evaluate the relation between temperature and risk of death related to cocaine, opioids and amphetamines in British Columbia, Canada.

METHODS

We extracted data on all deaths with cocaine, opioid or amphetamine toxicity recorded as an underlying or contributing cause from BC vital statistics for 1998-2017. We used a time-stratified case-crossover design to estimate the effect of temperature on the risk of death associated with acute drug toxicity during the warmer months (May through September). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for each 10°C increase in the 2-day average maximum temperature at the residential location.

RESULTS

We included 4913 deaths in the analyses. A 10°C increase in the 2-day average maximum temperature was associated with an OR of 1.43 (95% CI 1.11-1.86) for deaths with only cocaine toxicity recorded (n = 561), an OR of 1.15 (95% CI 0.99-1.33) for deaths with opioids only (n = 1682) and an OR of 1.11 (95% CI 0.60-2.04) for deaths with amphetamines only (n = 133). There were also elevated effects when toxicity from multiple drugs was recorded. Sensitivity analyses showed differences in the ORs by sex, by climatic region, and when the location of death was used instead of the location of residence.

INTERPRETATION

Increasing temperatures were associated with higher odds of death due to drug toxicity, especially for cocaine alone and combined with other drugs. Targeted interventions are necessary to prevent death associated with toxic drug use during hot weather.

Prescribing cascades in community-dwelling adults: A systematic review

The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. A systematic review was reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline [Ovid], EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: community-dwelling adults; risk-prescription medication; outcomes-initiation of new medicine to "treat" or reduce ADR risk; study type-cohort, cross-sectional, case-control, and case-series studies. Title/abstract screening, full-text screening, data extraction, and methodological quality assessment were conducted independently in duplicate. A narrative synthesis was conducted. A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11 593 989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n = 5), amiodarone to levothyroxine (n = 5), inhaled corticosteroid to topical antifungal (n = 4), antipsychotic to anti-Parkinson drug (n = 4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n = 4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months.

Psoriasis and sexual dysfunction: links, risks, and management challenges

According to the WHO, sexual health is not merely the absence of disease. Sexual dysfunction may be present in 40.8% of psoriasis patients, furthermore, 68% prevalence was found in Brazilian women with psoriasis. The moderate prevalence of psoriatic lesions in the genital area (35%-42%) does not explain the alarming prevalence of sexual dysfunction. Other factors, such as anxiety, depression, and also psoriasis treatment may contribute to its development. Likewise, atherosclerosis of the pelvic vasculature is involved in the pathogenesis of erectile dysfunction. Risk factors for erectile dysfunction tend to be confused with the comorbidities seen in psoriasis patients. We also highlight that it may serve as a marker of cardiovascular risk.

The case-crossover study design in pharmacoepidemiology

In the study of the association of transient drug exposures with acute outcomes, the case-crossover design is an efficient alternative to the case-control approach. This design based exclusively on the case series uses within-subject comparisons of drug exposures over time to estimate the rate ratio of the outcome associated with the drug under study. This design inherently removes the biasing effects of unmeasured, time-invariant confounding factors from the estimated rate ratio, but is sensitive to several assumptions. We illustrated the case-crossover design and explored its sensitivity using data from 4028 cases of gastrointestinal bleeding from the General Practice Research Database in assessing the effects of the drug warfarin. We compared the use of different time window lengths to assess exposure and considered the use of a case-time-control design to account for exposure time trends. The case-crossover approach found no excess risk of bleeding with warfarin exposure [rate ratio 0.98; 95% confidence interval (CI): 0.74-1.28] using a 1-month time window. When we restricted the analysis to subjects with truly transient drug exposure, defined by 1 to 3 prescriptions in the previous year, the rate ratio was 2.59 (95% CI: 1.42-4.74). To consider the longer 1-year exposure time window, the case-time-control approach was used and resulted in a rate ratio of 1.72 (95% CI: 1.08-2.43). In conclusion, the case-crossover design is potentially a powerful approach to assess the risk of drugs. This design is, however, highly sensitive to assumptions about intermittency of drug use and the length of the exposure time window, as demonstrated with the example of bleeding associated with warfarin use.

Differential Misclassification of Exposure in Case-Crossover Studies

The aim of this study is to examine 2 types of differential misclassification of exposure in case-crossover studies. The first is the outcome-dependent misclassification of exposure, meaning that if an event has occurred, it could affect the reporting of exposure. The second is differential misclassification of exposure as a result of fading memory over time, which arises if the length of the recall period for case and control windows differs. We use empirical data from a case-crossover study of triggers of attacks in Ménière's disease. The study applied the matched-pair interval control window sampling approach. We examined misclassification in relation to 2 different types of exposures: emotional stress and salty food intake. The study covered repeated events reported by the same patients and involved the sampling of many control windows. Because some of these windows were related to case events and some unrelated, we were able to conduct both case-crossover and control-crossover analyses. Although this group of Ménière patients are well aware of their disease, and many of them have definite ideas regarding what triggers attacks, neither outcome-dependent misclassification nor differential misclassification of exposure resulting from fading memory over time seemed to be a major problem.

Selective serotonin reuptake inhibitor-induced urinary incontinence

PURPOSE

Irrespective of its cause, urinary incontinence is a medical condition seriously affecting quality of life and is increasingly recognized. In this study, we examined the association between the use of selective serotonin reuptake inhibitors (SSRIs) and urinary incontinence.

METHODS

A retrospective follow-up study among starters with an SSRI was performed to estimate the relative and absolute risk for urinary incontinence associated with SSRI use. Data came from the PHARMO database, which includes information on drug dispensing for approximately 450,000 residents living in eight Dutch cities. All patients initially using an SSRI between 1994 and 1998 were selected. The frequency measures for urinary incontinence were estimated by using prescription sequence analysis, where initiation of spasmolytic drugs or absorbent products was used as a measure for urinary incontinence. Besides crude incidence density calculations, Andersen-Gill's model was used in order to control for possible confounding factors and time varying covariates.

RESULTS

A total of 13,531 were identified as first time users of an SSRI. Compared to non-exposure, the incidence density ratio for urinary incontinence during SSRI exposure was 1.75 (95% CI 1.56-1.97). Overall, compared to baseline, SSRI use caused 14 extra cases of urinary incontinence per 1000 patients treated per year; the elderly were more at risk resulting in 60 extra cases per 1000 patients per year. The adjusted relative risk for urinary incontinence due to SSRI use was 1.61 (95% CI 1.42-1.82); the risk for sertraline users was 2.76; 95% CI 1.47-5.21).

CONCLUSIONS

Exposure to SSRIs is associated with an increased risk for developing urinary incontinence, which can be explained pharmacologically. Approximately 15 out of 1000 patients treated per year with an SSRI developed urinary incontinence. The elderly and users of sertraline are at the highest risk.

Should we use a case-crossover design?

The first decade of experience with case-crossover studies has shown that the design applies best if the exposure is intermittent, the effect on risk is immediate and transient, and the outcome is abrupt. However, this design has been used to study single changes in exposure level, gradual effects on risk, and outcomes with insidious onsets. To estimate relative risk, the exposure frequency during a window just before outcome onset is compared with exposure frequencies during control times rather than in control persons. One or more control times are supplied by each of the cases themselves, to control for confounding by constant characteristics and self-confounding between the trigger's acute and chronic effects. This review of published case-crossover studies is designed to help the reader prepare a better research proposal by understanding triggers and deterrents, target person times, alternative study bases, crossover cohorts, induction times, effect and hazard periods, exposure windows, the exposure opportunity fallacy, a general likelihood formula, and control crossover analysis.

Systemic retinoids. What's new?

Despite major advances in the molecular biology and pharmacology of retinoids, no new compound has been developed for systemic use. This article addresses some questions related to the indications of oral retinoids already on the market, e.g. isotretinoin, acitretin, as well as tretinoin, reviews some recently reported undesirable effects, and discusses the recent concepts generated by basic research that may lead to new drugs to be used in pharmacology.

Interpretation and bias in case-crossover studies

The case-crossover design is an innovative epidemiologic technique with distinct strengths and limitations. We review the fundamental logic of this self-matching non-randomized design and direct attention to 15 concerns related to the available data, unavailable data, analytic technique, quantitative statistics, and etiologic model. Implications for each concern are discussed in the context of a recent report on whether cellular telephone calls are associated with an increased risk of a motor vehicle collision. We suggest that an understanding of the case-crossover design may help investigators explore selected questions in behavioral medical research.