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Kanning JP, Abtahi S, Schnier C, Klungel OH, Geerlings MI, Ruigrok YM. Prescribed Drug Use and Aneurysmal Subarachnoid Hemorrhage Incidence: A Drug-Wide Association Study. Neurology 2024; 102:e209479. [PMID: 38838229 PMCID: PMC11226321 DOI: 10.1212/wnl.0000000000209479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/26/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Current benefits of invasive intracranial aneurysm treatment to prevent aneurysmal subarachnoid hemorrhage (aSAH) rarely outweigh treatment risks. Most intracranial aneurysms thus remain untreated. Commonly prescribed drugs reducing aSAH incidence may provide leads for drug repurposing. We performed a drug-wide association study (DWAS) to systematically investigate the association between commonly prescribed drugs and aSAH incidence. METHODS We defined all aSAH cases between 2000 and 2020 using International Classification of Diseases codes from the Secure Anonymised Information Linkage databank. Each case was matched with 9 controls based on age, sex, and year of database entry. We investigated commonly prescribed drugs (>2% in study population) and defined 3 exposure windows relative to the most recent prescription before index date (i.e., occurrence of aSAH): current (within 3 months), recent (3-12 months), and past (>12 months). A logistic regression model was fitted to compare drug use across these exposure windows vs never use, controlling for age, sex, known aSAH risk factors, and health care utilization. The family-wise error rate was kept at p < 0.05 through Bonferroni correction. RESULTS We investigated exposure to 205 commonly prescribed drugs between 4,879 aSAH cases (mean age 61.4, 61.2% women) and 43,911 matched controls. We found similar trends for lisinopril and amlodipine, with a decreased aSAH risk for current use (lisinopril odds ratio [OR] 0.63, 95% CI 0.44-0.90, amlodipine OR 0.82, 95% CI 0.65-1.04) and an increased aSAH risk for recent use (lisinopril OR 1.30, 95% CI 0.61-2.78, amlodipine OR 1.61, 95% CI 1.04-2.48). A decreased aSAH risk in current use was also found for simvastatin (OR 0.78, 95% CI 0.64-0.96), metformin (OR 0.58, 95% CI 0.43-0.78), and tamsulosin (OR 0.55, 95% CI 0.32-0.93). By contrast, an increased aSAH risk was found for current use of warfarin (OR 1.35, 95% CI 1.02-1.79), venlafaxine (OR 1.67, 95% CI 1.01-2.75), prochlorperazine (OR 2.15, 95% CI 1.45-3.18), and co-codamol (OR 1.31, 95% CI 1.10-1.56). DISCUSSION We identified several drugs associated with aSAH, of which 5 drugs (lisinopril and possibly amlodipine, simvastatin, metformin, and tamsulosin) showed a decreased aSAH risk. Future research should build on these signals to further assess the effectiveness of these drugs in reducing aSAH incidence. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that some commonly prescribed drugs are associated with subsequent development of aSAH.
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Affiliation(s)
- Jos P Kanning
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Shahab Abtahi
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Christian Schnier
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Olaf H Klungel
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Mirjam I Geerlings
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
| | - Ynte M Ruigrok
- From the UMC Utrecht Brain Center (J.P.K., Y.M.R.), Department of Neurology and Neurosurgery, University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care (J.P.K., O.H.K., M.I.G.), University Medical Center Utrecht, and Division of Pharmacoepidemiology and Clinical Pharmacology (S.A., O.H.K.), Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands; Infection Medicine (C.S.), Edinburgh Medical School, The University of Edinburgh, United Kingdom; Department of General Practice (M.I.G.), Amsterdam UMC, location University of Amsterdam; Amsterdam Public Health, Aging & Later Life, and Personalized Medicine (M.I.G.); and Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep (M.I.G.), the Netherlands
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Delvin T, Bygum A, Lund LC, Andersen JH, Hallas J. Screening of dermatology drugs for aberrant use-patterns: An application of epidemiologic estimates and measures of inequality in drug use. Br J Clin Pharmacol 2024; 90:1450-1462. [PMID: 38469942 DOI: 10.1111/bcp.16037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/16/2023] [Accepted: 02/01/2024] [Indexed: 03/13/2024] Open
Abstract
AIMS Dermatology treatments require adherence for safe and effective use. Real-world healthcare databases can reveal drug utilization patterns and uncover inappropriate or unexpected use. This study aimed to analyse dermatology drug utilization patterns using epidemiological and inequality measures, leveraging Danish nationwide registries. It also assessed the feasibility of this method for detecting aberrant drug use. METHODS We formed a 2019 cohort of all patients treated for skin conditions through Danish healthcare registries. We calculated prevalence, incidence rates and treatment duration for dermatological drugs. Inequality in drug utilization was assessed using Lorenz curves, Gini coefficients and other measures. RESULTS The study encompassed 1 021 255 patients using 94 dermatology drugs. Most usage aligned with 'expected clinical use', but we detected inequality, with some drugs having high Gini coefficients and disproportionate consumption by the top percentile of users. Notable findings included potential inappropriate antibiotic use, excessive topical corticosteroid use and unexpected drug use duration. CONCLUSIONS In Denmark, dermatology drugs are used primarily as anticipated, with minimal unexpected patterns. Specific follow-up is required to draw conclusions about inappropriate use. This approach demonstrates broad applicability for screening aberrant drug utilization.
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Affiliation(s)
- Thomas Delvin
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Institute of Public Health, University of Southern Denmark, Odense C, Denmark
- R&D Medical Sciences, LEO Pharma, Ballerup, Denmark
| | - Anette Bygum
- Clinical Institute, University of Southern Denmark, Odense C, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense C, Denmark
| | - Lars Christian Lund
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Institute of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jacob Harbo Andersen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Institute of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jesper Hallas
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Institute of Public Health, University of Southern Denmark, Odense C, Denmark
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Delvin T, Bygum A, Lund LC, Andersen JH, Hallas J. Application of the waiting time distribution in a nationwide screening of real-world dermatology drug utilization for aberrant use patterns. Pharmacoepidemiol Drug Saf 2024; 33:e5720. [PMID: 37885413 DOI: 10.1002/pds.5720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/23/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Inappropriate use of medicines may have critical consequences from individual, public health, and economic perspectives. Discovering wrongful medicine use may require intentional surveillance or screening. OBJECTIVES The objectives of this study were to: (i) apply and evaluate the waiting time distribution (WTD) method as a screening tool for identifying aberrant drug use and (ii) evaluate the nationwide use of Dermatology drugs in Denmark for signals of aberrant drug use. METHOD Dermatology drug use data from the Danish nationwide healthcare registries from 2018 to 2020 were used to produce WTDs that were analyzed for drug use patterns. The method provides estimates of the prevalence and incidence and enables estimation of mean treatment duration, drug relapse, and unexpected drug prescribing. RESULTS The study included 2 027 889 individual drug users and analyzed 6 141 449 prescriptions. The analysis included approximately 100 dermatology drugs and drug categories and produced 56 WTD drug curves. The WTD patterns and epidemiological estimates confirmed that most drugs are used as intended and revealed few unexpected patterns for further investigation. Three unexpected findings were identified concerning (i) short-term use that would entail suboptimal clinical efficiency for minoxidil, (ii) sub-optimal use of topical tacrolimus, and (iii) potential undesirable increase in short-course doxycycline treatments. CONCLUSION In Denmark, dermatology drugs are predominantly used as expected, with few unexpected use patterns identified. Targeted specific follow-up on the identified signals is necessary for conclusions about inappropriate use. The findings suggest that the WTD method is applicable for screening for aberrant drug use.
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Affiliation(s)
- Thomas Delvin
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
- LEO Pharma, R&D Medical Sciences, Ballerup, Denmark
| | - Anette Bygum
- Clinical Institute, University of Southern Denmark, Odense C, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense C, Denmark
| | - Lars Christian Lund
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jacob Harbo Andersen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jesper Hallas
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
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Woo HT, Jeong SY, Shin A. The association between prescription drugs and colorectal cancer prognosis: a nationwide cohort study using a medication-wide association study. BMC Cancer 2023; 23:643. [PMID: 37430209 DOI: 10.1186/s12885-023-11105-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 06/23/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND With the availability of health insurance claim data, pharmacovigilance for various drugs has been suggested; however, it is necessary to establish an appropriate analysis method. To detect unintended drug effects and to generate new hypotheses, we conducted a hypothesis-free study to systematically examine the relationship between all prescription nonanticancer drugs and the mortality of colorectal cancer patients. METHODS We used the Korean National Health Insurance Service-National Sample Cohort database. A total of 2,618 colorectal cancer patients diagnosed between 2004 and 2015 were divided into drug discovery and drug validation sets (1:1) through random sampling. Drugs were classified using the Anatomical Therapeutic Chemical (ATC) classification system: 76 drugs classified as ATC level 2 and 332 drugs classified as ATC level 4 were included in the analysis. We used a Cox proportional hazard model adjusted for sex, age, colorectal cancer treatment, and comorbidities. The relationship between all prescription nonanticancer drugs and the mortality of colorectal cancer patients was analyzed, controlling for multiple comparisons with the false discovery rate. RESULTS We found that one ATC level-2 drug (drugs that act on the nervous system, including parasympathomimetics, addictive disorder drugs, and antivertigo drugs) showed a protective effect related to colorectal cancer prognosis. At the ATC level 4 classification, 4 drugs were significant: two had a protective effect (anticholinesterases and opioid anesthetics), and the other two had a detrimental effect (magnesium compounds and Pregnen [4] derivatives). CONCLUSIONS In this hypothesis-free study, we identified four drugs linked to colorectal cancer prognosis. The MWAS method can be useful in real-world data analysis.
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Affiliation(s)
- Hyeong-Taek Woo
- Department of Preventive Medicine, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo- gu, Daegu, 42601, Korea.
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Aesun Shin
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
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Coste A, Wong A, Bokern M, Bate A, Douglas IJ. Methods for drug safety signal detection using routinely collected observational electronic health care data: A systematic review. Pharmacoepidemiol Drug Saf 2023; 32:28-43. [PMID: 36218170 PMCID: PMC10092128 DOI: 10.1002/pds.5548] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/21/2022] [Accepted: 10/02/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE Signal detection is a crucial step in the discovery of post-marketing adverse drug reactions. There is a growing interest in using routinely collected data to complement established spontaneous report analyses. This work aims to systematically review the methods for drug safety signal detection using routinely collected healthcare data and their performance, both in general and for specific types of drugs and outcomes. METHODS We conducted a systematic review following the PRISMA guidelines, and registered a protocol in PROSPERO. MEDLINE, EMBASE, PubMed, Web of Science, Scopus, and the Cochrane Library were searched until July 13, 2021. RESULTS The review included 101 articles, among which there were 39 methodological works, 25 performance assessment papers, and 24 observational studies. Methods included adaptations from those used with spontaneous reports, traditional epidemiological designs, methods specific to signal detection with real-world data. More recently, implementations of machine learning have been studied in the literature. Twenty-five studies evaluated method performances, 16 of them using the area under the curve (AUC) for a range of positive and negative controls as their main measure. Despite the likelihood that performance measurement could vary by drug-event pair, only 10 studies reported performance stratified by drugs and outcomes, in a heterogeneous manner. The replicability of the performance assessment results was limited due to lack of transparency in reporting and the lack of a gold standard reference set. CONCLUSIONS A variety of methods have been described in the literature for signal detection with routinely collected data. No method showed superior performance in all papers and across all drugs and outcomes, performance assessment and reporting were heterogeneous. However, there is limited evidence that self-controlled designs, high dimensional propensity scores, and machine learning can achieve higher performances than other methods.
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Affiliation(s)
- Astrid Coste
- Department of Non-Communicable Disease Epidemiology, LSHTM, London, UK
| | - Angel Wong
- Department of Non-Communicable Disease Epidemiology, LSHTM, London, UK
| | - Marleen Bokern
- Department of Non-Communicable Disease Epidemiology, LSHTM, London, UK
| | - Andrew Bate
- Department of Non-Communicable Disease Epidemiology, LSHTM, London, UK.,Global Safety, GSK, Brentford, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, LSHTM, London, UK
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Reyes C, León-Muñoz LM, Pistillo A, Jóhannesdóttir Schmidt SA, Kristensen KB, Puente D, LLorente-García A, Huerta-Álvarez C, Pottegård A, Duarte-Salles T. Flecainide and risk of skin neoplasms: Results of a large nested case-control study in Spain and Denmark. Front Pharmacol 2022; 13:1002451. [PMID: 36618916 PMCID: PMC9822716 DOI: 10.3389/fphar.2022.1002451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
Background: A previous study in Denmark suggested an increased melanoma risk associated with the use of flecainide. Objective: To study the association between flecainide use and the risk of melanoma and non-melanoma skin cancer in Spain and Denmark. Methods: We conducted a multi-database case-control study in (database/study period) Spain (SIDIAP/2005-2017 and BIFAP/2007-2017) and Denmark (Danish registries/2001-2018). We included incident cases of melanoma or non-melanoma skin cancer (NMSC) aged ≥18 with ≥2 years of previous data (≥10 years for Denmark) before the skin cancer and matched them to controls (10:1 by age and sex). We excluded persons with immunosuppression or previous cancer. We defined ever-use as any prescription fill and high-use as a cumulative dose of at least 200 g (reference: never-use). We categorized a cumulative dose for a dose-response assessment. We used conditional logistic regression to compute ORs (95% CI) adjusted for photosensitizing, anti-neoplastic, disease-specific drugs and comorbidities. Results: The total numbers of melanoma/NMSC cases included were 7,809/64,230 in SIDIAP, 4,661/31,063 in BIFAP, and 27,978/152,821 in Denmark. In Denmark, high-use of flecainide was associated with increased adjusted ORs of skin cancer compared with never-use [melanoma: OR 1.97 (1.38-2.81); NMSC: OR 1.34 (1.15-1.56)]. In Spain, an association between high-use of flecainide and NMSC was also observed [BIFAP: OR 1.42 (1.04-1.93); SIDIAP: OR 1.19 (0.95-1.48)]. There was a non-significant dose-response pattern for melanoma in Denmark and no apparent dose-response pattern for NMSC in any of the three databases. We found similar results for ever-use of flecainide. Conclusion: Flecainide use was associated with an increased risk of melanoma (Denmark only) and NMSC (Denmark and Spain) but without substantial evidence of dose-response patterns. Further studies are needed to assess for possible unmeasured confounders.
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Affiliation(s)
- Carlen Reyes
- Fundació Institut Universitari per a la Recerca a L'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Luz M León-Muñoz
- Delegation for the National Plan on Drugs, Ministry of Health, Madrid, Spain
| | - Andrea Pistillo
- Fundació Institut Universitari per a la Recerca a L'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Sigrún Alba Jóhannesdóttir Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Bruun Kristensen
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Diana Puente
- Fundació Institut Universitari per a la Recerca a L'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Ana LLorente-García
- Pharmacoepiemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Clinical Devices-AEMPS, Madrid, Spain
| | - Consuelo Huerta-Álvarez
- Department of Public Health & Maternal and Child Health, Faculty of Medicine. Complutense University of Madrid-UCM, Madrid, Spain
| | - Anton Pottegård
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Talita Duarte-Salles
- Fundació Institut Universitari per a la Recerca a L'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
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Kristensen KB, Friis S, Lund LC, Hallas J, Cardwell CR, Andreassen BK, Habel LA, Pottegård A. Identification of Drug-Cancer Associations: A Nationwide Screening Study. CANCER RESEARCH COMMUNICATIONS 2022; 2:552-560. [PMID: 36923552 PMCID: PMC10010324 DOI: 10.1158/2767-9764.crc-22-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/24/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022]
Abstract
The main tool in drug safety monitoring, spontaneous reporting of adverse effects, is unlikely to detect delayed adverse drug effects including cancer. Hypothesis-free screening studies based on administrative data could improve ongoing drug safety monitoring. Using Danish health registries, we conducted a series of case-control studies by identifying individuals with incident cancer in Denmark from 2001 to 2018, matching each case with 10 population controls on age, sex, and calendar time. ORs were estimated using conditional logistic regression accounting for matching factors, educational level, and selected comorbidities. A total of 13,577 drug-cancer associations were examined for individual drugs and 8,996 for drug classes. We reviewed 274 drug-cancer pairs where an association with high use and a cumulative dose-response pattern was present. We classified 65 associations as not readily attributable to bias of which 20 were established as carcinogens by the International Agency for Research on Cancer and the remaining 45 associations may warrant further study. The screening program identified drugs with known carcinogenic effects and highlighted a number of drugs that were not established as carcinogens and warrant further study. The effect estimates in this study should be interpreted cautiously and will need confirmation targeted epidemiologic and translational studies. Significance This study provides a screening tool for drug carcinogenicity aimed at hypothesis generation and explorative purposes. As such, the study may help to identify drugs with unknown carcinogenic effects and, ultimately, improve drug safety as part of the ongoing safety monitoring of drugs.
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Affiliation(s)
- Kasper Bruun Kristensen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Søren Friis
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
| | - Lars Christian Lund
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Chris R. Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | | | - Laurel A. Habel
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Anton Pottegård
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Pottegård A. Core Concepts in Pharmacoepidemiology: Fundamentals of the cohort and case-control study designs. Pharmacoepidemiol Drug Saf 2022; 31:817-826. [PMID: 35621007 PMCID: PMC9545534 DOI: 10.1002/pds.5482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/09/2022]
Abstract
In this review paper, I outline the principles of the cohort as a sampling frame and provide a basic introduction to the cohort study design and the case–control study design, two of the most important designs in the pharmacoepidemiologist's toolbox. Further, I discuss when to prefer one design over the other. The paper is intended as a primer for people new to the field of pharmacoepidemiology and contains a range of suggestions for additional reading regarding the study designs and related epidemiological topics.
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Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Wang Y, Gadalla SM. Drug-Wide Association Study (DWAS): Challenges and Opportunities. Cancer Epidemiol Biomarkers Prev 2021; 30:597-599. [PMID: 33811172 DOI: 10.1158/1055-9965.epi-20-1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/17/2020] [Accepted: 01/19/2021] [Indexed: 11/16/2022] Open
Abstract
Cancer risk associations with commonly prescribed medications have been mainly evaluated in hypothesis-driven studies that focus on one drug at a time. Agnostic drug-wide association studies (DWAS) offer an alternative approach to simultaneously evaluate associations between a large number of drugs with one or more cancers using large-scale electronic health records. Although cancer DWAS approaches are promising, a number of challenges limit their applicability. This includes the high likelihood of false positivity; lack of biological considerations; and methodological shortcomings, such as inability to tightly control for confounders. As such, the value of DWAS is currently restricted to hypothesis generation with detected signals needing further evaluation. In this commentary, we discuss those challenges in more detail and summarize the approaches to overcome them by using published cancer DWAS studies, including the accompanied article by Støer and colleagues. Despite current concerns, DWAS future is filled with opportunities for developing innovative analytic methods and techniques that incorporate pharmacology, epidemiology, cancer biology, and genetics.See related article by Støer et al., p. 682.
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Affiliation(s)
- Youjin Wang
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Shahinaz M Gadalla
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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Støer NC, Botteri E, Thoresen GH, Karlstad Ø, Weiderpass E, Friis S, Pottegård A, Andreassen BK. Drug Use and Cancer Risk: A Drug-Wide Association Study (DWAS) in Norway. Cancer Epidemiol Biomarkers Prev 2021; 30:682-689. [PMID: 33144282 DOI: 10.1158/1055-9965.epi-20-1028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/11/2020] [Accepted: 10/22/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Population-based pharmaco-epidemiologic studies are used to assess postmarketing drug safety and discover beneficial effects of off-label drug use. We conducted a drug-wide association study (DWAS) to screen for associations between prescription drugs and cancer risk. METHODS This registry-based, nested case-control study, 1:10 matched on age, sex, and date of diagnosis of cases, comprises approximately 2 million Norwegian residents, including their drug history from 2004 to 2014. We evaluated the association between prescribed drugs, categorized according to the anatomical therapeutic chemical (ATC) classification system, and the risk of the 15 most common cancer types, overall and by histology. We used stratified Cox regression, adjusted for other drug use, comorbidity, county, and parity, and explored dose-response trends. RESULTS We found 145 associations among 1,230 drug-cancer combinations on the ATC2-level and 77 of 8,130 on the ATC4-level. Results for all drug-cancer combinations are presented in this article and an online tool (https://pharmacoepi.shinyapps.io/drugwas/). Some associations have been previously reported, that is, menopausal hormones and breast cancer risk, or are likely confounded, that is, chronic obstructive pulmonary diseases and lung cancer risk. Other associations were novel, that is, inverse association between proton pump inhibitors and melanoma risk, and carcinogenic association of propulsives and lung cancer risk. CONCLUSIONS This study confirmed previously reported associations and generated new hypotheses on possible carcinogenic or chemopreventive effects of prescription drugs. Results from this type of explorative approach need to be validated in tailored epidemiologic and preclinical studies. IMPACT DWAS studies are robust and important tools to define new drug-cancer hypotheses.See related commentary by Wang and Gadalla, p. 597.
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Affiliation(s)
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - G Hege Thoresen
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway
| | - Øystein Karlstad
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Elisabete Weiderpass
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Søren Friis
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
| | - Anton Pottegård
- Department of Public Health, Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
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11
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McDowell RD, Hughes C, Murchie P, Cardwell C. A systematic assessment of the association between frequently prescribed medicines and the risk of common cancers: a series of nested case-control studies. BMC Med 2021; 19:22. [PMID: 33494748 PMCID: PMC7836181 DOI: 10.1186/s12916-020-01891-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/15/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Studies systematically screening medications have successfully identified prescription medicines associated with cancer risk. However, adjustment for confounding factors in these studies has been limited. We therefore investigated the association between frequently prescribed medicines and the risk of common cancers adjusting for a range of confounders. METHODS A series of nested case-control studies were undertaken using the Primary Care Clinical Informatics Unit Research (PCCIUR) database containing general practice (GP) records from Scotland. Cancer cases at 22 cancer sites, diagnosed between 1999 and 2011, were identified from GP records and matched with up to five controls (based on age, gender, GP practice and date of registration). Odds ratios (OR) and 95% confidence intervals (CI) comparing any versus no prescriptions for each of the most commonly prescribed medicines, identified from prescription records, were calculated using conditional logistic regression, adjusting for comorbidities. Additional analyses adjusted for smoking use. An association was considered a signal based upon the magnitude of its adjusted OR, p-value and evidence of an exposure-response relationship. Supplementary analyses were undertaken comparing 6 or more prescriptions versus less than 6 for each medicine. RESULTS Overall, 62,109 cases and 276,580 controls were included in the analyses and a total of 5622 medication-cancer associations were studied across the 22 cancer sites. After adjusting for comorbidities 2060 medicine-cancer associations for any prescription had adjusted ORs greater than 1.25 (or less than 0.8), 214 had a corresponding p-value less than or equal to 0.01 and 118 had evidence of an exposure-dose relationship hence meeting the criteria for a signal. Seventy-seven signals were identified after additionally adjusting for smoking. Based upon an exposure of 6 or more prescriptions, there were 118 signals after adjusting for comorbidities and 82 after additionally adjusting for smoking. CONCLUSIONS In this study a number of novel associations between medicine and cancer were identified which require further clinical and epidemiological investigation. The majority of medicines were not associated with an altered cancer risk and many identified signals reflected known associations between medicine and cancer.
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Affiliation(s)
- R. D. McDowell
- Centre for Public Health, Queen’s University, Grosvenor Rd., Belfast, Co. Antrim BT12 6BA UK
| | - C. Hughes
- School of Pharmacy, Queen’s University, Lisburn Rd, Belfast, Co. Antrim BT9 7BL UK
| | - P. Murchie
- Division of Applied Health Sciences Section, Section of Academic Primary Care, Foresterhill, Aberdeen, AB24 2ZD UK
| | - C. Cardwell
- Centre for Public Health, Queen’s University, Grosvenor Rd., Belfast, Co. Antrim BT12 6BA UK
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12
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Berge LAM, Andreassen BK, Stenehjem JS, Heir T, Karlstad Ø, Juzeniene A, Ghiasvand R, Larsen IK, Green AC, Veierød MB, Robsahm TE. Use of Immunomodulating Drugs and Risk of Cutaneous Melanoma: A Nationwide Nested Case-Control Study. Clin Epidemiol 2020; 12:1389-1401. [PMID: 33376408 PMCID: PMC7755337 DOI: 10.2147/clep.s269446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/08/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose Cutaneous melanoma is among the fastest growing malignancies in Norway and ultraviolet radiation (UVR) exposure is the primary environmental risk factor. Immunomodulating drugs can increase skin photosensitivity and suppress immune responses, and by such mechanisms influence melanoma risk. We, therefore, aimed to examine the associations between use of immunomodulating drugs and melanoma risk, at a nationwide population level. Patients and Methods In the Cancer Registry of Norway, we identified all cases aged 18-85 with a first primary cutaneous melanoma diagnosed in 2007-2015 (n=12,106). These were matched to population controls from the Norwegian National Registry 1:10 (n=118,564), on sex and year of birth using risk set sampling. Information on prescribed drugs (2004-2015) was obtained by linkage to the Norwegian Prescription Database (NorPD). Conditional logistic regression was used to estimate rate ratios (RRs) and 95% confidence intervals (CIs) for associations between use of immunomodulating drugs (immunosuppressants and corticosteroids) and melanoma risk, adjusted for ambient UVR and other drug use. Results Compared with ≤1 prescription, use of ≥8 prescriptions of immunosuppressants was associated with increased risk of melanoma (RR 1.50, 95% CI 1.27, 1.77). Similar associations were found for subgroups of immunosuppressants: drugs typically prescribed to organ transplant recipients (OTRs) (RR 2.02, 95% CI 1.35, 3.03) and methotrexate (RR 1.27, 95% CI 1.04, 1.55). Similar results were found for high levels of cumulative doses and across all histological subtypes. Use of corticosteroids was not associated with melanoma risk. Conclusion We found a positive association between use of immunosuppressants and melanoma risk, with the highest risk seen for drugs prescribed to OTRs. Knowledge about this risk increase is important for physicians and users of these drugs, for intensified surveillance, awareness and cautious sun exposure.
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Affiliation(s)
- Leon Alexander Mclaren Berge
- Department of Research, Cancer Registry of Norway, Oslo, Norway.,Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | | | - Jo Steinson Stenehjem
- Department of Research, Cancer Registry of Norway, Oslo, Norway.,Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Trond Heir
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Oslo Ischemia Study, Oslo University Hospital, Oslo, Norway
| | - Øystein Karlstad
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Asta Juzeniene
- Department of Radiation Biology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Reza Ghiasvand
- Department of Research, Cancer Registry of Norway, Oslo, Norway.,Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | | | - Adele C Green
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Australia.,Molecular Oncology Unit, CRUK Manchester Institute, University of Manchester, Manchester, UK
| | - Marit Bragelien Veierød
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Trude Eid Robsahm
- Department of Research, Cancer Registry of Norway, Oslo, Norway.,Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
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13
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Risk of Renal Cell Carcinoma Associated with Calcium Channel Blockers: A Nationwide Observational Study Focusing on Confounding by Indication. Epidemiology 2020; 31:860-871. [PMID: 32897909 DOI: 10.1097/ede.0000000000001256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND We examined whether the apparent association between renal cell carcinoma (RCC) and use of dihydropyridine calcium channel blockers (CCBs) was explained by confounding by indication since hypertension, the main indication for CCBs, is a risk factor for RCC. METHODS Using Danish health registries, we conducted a nested case-control study including 7315 RCC cases during 2000-2015. We matched each case with up to 20 controls on age and sex using risk-set sampling. We estimated odds ratios (ORs) for long-term CCB use associated with RCC using conditional logistic regression. We addressed confounding by indication by (1) adjusting for hypertension severity indicators; (2) evaluating dose-response patterns; (3) examining whether other first-line anti-hypertensives were associated with RCC; and (4) using an active comparator new user design by nesting the study in new users of CCBs or angiotensin-converting enzyme inhibitors (ACEIs). RESULTS The adjusted OR for RCC associated with long-term CCB use compared to non-use was 1.76 (1.63-1.90). After we additionally adjusted for hypertension severity indicators, the OR remained elevated (OR 1.37; confidence interval [CI] 1.25, 1.49) with evidence of a dose-response pattern. Other anti-hypertensives were also associated with RCC, for example, ACEIs (OR 1.27; 95% CI = 1.16, 1.39) and thiazides (OR 1.22; 95% CI = 1.12, 1.34). In the active comparator new user design, the OR was 1.21 (95% CI = 0.95, 1.53) for use of CCBs compared with ACEIs. CONCLUSIONS In this population, confounding by indication appeared to explain at least part of the association between RCC and dihydropyridine CCBs.
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14
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Kemp K, Brun NC, Quartarolo JP. Advanced analytics – translating registry science into regulatory actions. Expert Opin Drug Saf 2020; 19:533-535. [DOI: 10.1080/14740338.2020.1736555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Kåre Kemp
- Pharmacovigilance and Medical Devices, Danish Medicines Agency, Copenhagen, Denmark
| | - Nikolai C. Brun
- Medical Evaluation and Biostatistics, Danish Medicines Agency, Copenhagen, Denmark
| | - Jens P. Quartarolo
- Pharmacovigilance and Medical Devices, Danish Medicines Agency, Copenhagen, Denmark
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15
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Pottegård A, Kristensen KB, Friis S, Hallas J, Jensen JB, Nørgaard M. Urinary tract infections and risk of squamous cell carcinoma bladder cancer: A Danish nationwide case-control study. Int J Cancer 2020; 146:1930-1936. [PMID: 31863454 DOI: 10.1002/ijc.32842] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/21/2019] [Accepted: 12/13/2019] [Indexed: 12/31/2022]
Abstract
Schistosoma haematobium infection can lead to squamous cell carcinomas (SCC) of the bladder. Whether this also applies to more common urinary tract infections (UTIs) is unclear. We therefore aimed to investigate the association between UTIs, reflected by the use of specific antibiotics and risk of SCC of the bladder. We conducted a Danish nationwide case-control study and identified histologically verified bladder cancer cases (2000-2015; n = 12,271) and age- and sex-matched cancer-free controls. We computed odds ratios (ORs) with 95% confidence intervals (CI) associating the use of UTI-specific antibiotics with SCC bladder cancer, using conditional logistic regression. We applied a 2-year lag-time to minimize reverse causation. To aid interpretation, similar analyses were performed for other bladder cancer types and other antibiotics. We identified 333 SCC cases (2.7% of all bladder cancers). Compared to no use (0-1 prescription), high-use (≥10 prescriptions) of UTI-specific antibiotics was associated with SCC with an OR of 11.4 (CI 7.6-17.2) and a clear dose-response pattern (ptrend < 0.001). Use of phenoxymethylpenicillin, an antibiotic not used against UTIs, was not associated with SCC after adjustment for use of UTI-specific antibiotics (OR 0.5). Furthermore, UTI-specific antibiotic use was not associated with urothelial carcinomas (n = 11,029; OR 1.13; CI 0.97-1.32). Excluding patients with known urogenital disease did not influence the SCC estimates (overall OR 10.8; CI 6.2-18.9). Data on smoking were lacking, however, a quantitative bias analysis suggested this to be of limited importance. In conclusion, common UTIs are strong, dose-dependent and specifically associated with risk of SCC of the bladder.
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Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Kasper B Kristensen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Søren Friis
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jørgen B Jensen
- Department of Urology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Arhus University Hospital, Aarhus, Denmark
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16
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Bate A, Hornbuckle K, Juhaeri J, Motsko SP, Reynolds RF. Hypothesis-free signal detection in healthcare databases: finding its value for pharmacovigilance. Ther Adv Drug Saf 2019; 10:2042098619864744. [PMID: 31428307 PMCID: PMC6683315 DOI: 10.1177/2042098619864744] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Andrew Bate
- Division of Translational Medicine, Department of Medicine, NYU School of Medicine, 462 1st Avenue, NY10016, New York, USA
| | - Ken Hornbuckle
- Global Patient Safety, Eli Lilly and Company, Indianapolis, IN, USA
| | - Juhaeri Juhaeri
- Juhaeri Juhaeri, Medical Evidence Generation, Sanofi US, Bridgewater, NJ, USA
| | | | - Robert F. Reynolds
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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17
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Hjellvik V, De Bruin ML, Samuelsen SO, Karlstad Ø, Andersen M, Haukka J, Vestergaard P, de Vries F, Furu K. Adjusting for unmeasured confounding using validation data: Simplified two-stage calibration for survival and dichotomous outcomes. Stat Med 2019; 38:2719-2734. [PMID: 30828842 DOI: 10.1002/sim.8131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/10/2018] [Accepted: 02/01/2019] [Indexed: 01/05/2023]
Abstract
In epidemiology, one typically wants to estimate the risk of an outcome associated with an exposure after adjusting for confounders. Sometimes, outcome and exposure and maybe some confounders are available in a large data set, whereas some important confounders are only available in a validation data set that is typically a subset of the main data set. A generally applicable method in this situation is the two-stage calibration (TSC) method. We present a simplified easy-to-implement version of the TSC for the case where the validation data are a subset of the main data. We compared the simplified version to the standard TSC version for incidence rate ratios, odds ratios, relative risks, and hazard ratios using simulated data, and the simplified version performed better than our implementation of the standard version. The simplified version was also tested on real data and performed well.
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Affiliation(s)
- Vidar Hjellvik
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Marie L De Bruin
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacy, Copenhagen Centre for Regulatory Science, University of Copenhagen, Copenhagen, Denmark
| | - Sven O Samuelsen
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway.,Department of Mathematics, University of Oslo, Oslo, Norway
| | - Øystein Karlstad
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Morten Andersen
- Centre for Pharmacoepidemiology, Karolinska Institutet, Clinical Epidemiology Division, Karolinska University Hospital, Solna, Sweden.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark.,Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Peter Vestergaard
- Department of Clinical Medicine and Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Frank de Vries
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Kari Furu
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
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18
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Andreassen BK, Støer NC, Martinsen JI, Ursin G, Weiderpass E, Thoresen GH, Debernard KB, Karlstad Ø, Pottegard A, Friis S. Identification of potential carcinogenic and chemopreventive effects of prescription drugs: a protocol for a Norwegian registry-based study. BMJ Open 2019; 9:e028504. [PMID: 30962244 PMCID: PMC6500356 DOI: 10.1136/bmjopen-2018-028504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Surveillance of unintended effects of pharmaceuticals (pharmacovigilance or drug safety) is crucial, as knowledge of rare or late side effects is limited at the time of the introduction of new medications into the market. Side effects of drugs may involve increased or decreased risk of cancer, but these typically appear after a long induction period. This fact, together with low incidences of many cancer types, limits the usefulness of traditional pharmacovigilance strategies, primarily based on spontaneous reporting of adverse events, to identify associations between drug use and cancer risk. Postmarketing observational pharmacoepidemiological studies are therefore crucial in the evaluation of drug-cancer associations. METHODS AND ANALYSIS The main data sources in this project will be the Norwegian Prescription Database and the Cancer Registry of Norway. The underlying statistical model will be based on a multiple nested case-control design including all adult (~200 000) incident cancer cases within the age-range 18-85 years from 2007 through 2015 in Norway as cases. 10 cancer-free population controls will be individually matched to these cases with respect to birth year, sex and index date (date of cancer diagnosis). Drug exposure will be modelled as chronic user/non-user by counting prescriptions, and cumulative use by summarising all dispensions' daily defined doses over time. Conditional logistic regression models adjusted for comorbidity (National Patient Register), socioeconomic parameters (Statistics Norway), concomitant drug use and, for female cancers, reproduction data (Medical Birth Registry), will be applied to identify drug-use-cancer-risk associations. ETHICS AND DISSEMINATION The study is approved by the regional ethical committee and the Norwegian data protection authority. Results of the initial screening step and analysis pipeline will be described in a key paper. Subsequent papers will report the evaluation of identified signals in replication studies. Results will be published in peer-reviewed journals, at scientific conferences and through press releases.
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Affiliation(s)
| | - Nathalie C Støer
- Norwegian National Advisory Unit on Women's Health, Women's Clinic, Oslo University Hospital, Oslo, Norway
| | | | | | - Elisabete Weiderpass
- Department of Research, Cancer Registry of Norway, Oslo, Norway
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Genetic Epidemiology Group, Folkhälsan Research Centerand Faculty of Medicine, Helsinki University, Helsinki, Finland
- Department of Community Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - G Hege Thoresen
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Section for Pharmacology and PharmaceuticalBiosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Karen Boldingh Debernard
- Regional Medicines Information and Pharmacovigilance Centre (RELIS), Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Øystein Karlstad
- Department of Chronic Diseases and Aging, Nasjonalt folkehelseinstitutt, Oslo, Norway
| | - Anton Pottegard
- Clinical Pharmacology and Pharmacy, Department ofPublic Health, University of Southern Denmark, Odense, Denmark
| | - Søren Friis
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
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19
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Pottegård A, Schmidt SAJ, Wallach-Kildemoes H, Sørensen HT, Hallas J, Schmidt M. Data Resource Profile: The Danish National Prescription Registry. Int J Epidemiol 2018; 46:798-798f. [PMID: 27789670 PMCID: PMC5837522 DOI: 10.1093/ije/dyw213] [Citation(s) in RCA: 431] [Impact Index Per Article: 71.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | | | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Regional Hospital of Randers, Randers, Denmark
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20
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Verdoodt F, Pottegård A, Dehlendorff C, Jäättelä M, Hallas J, Friis S, Kjaer SK. Antihistamine use and risk of ovarian cancer: A population-based case-control study. Maturitas 2018; 120:47-52. [PMID: 30583764 DOI: 10.1016/j.maturitas.2018.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/19/2018] [Accepted: 11/22/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Histamine is suggested to play a role in ovarian carcinogenesis. We examined the association between antihistamine use and ovarian cancer risk in a nationwide case-control study. STUDY DESIGN Cases (n = 5 556) comprised all women in Denmark aged 30-84 years with a histologically verified first diagnosis of epithelial ovarian cancer during 2000-2015. Age-matched population controls (n = 83 340) were selected using risk-set sampling. Data on prescription use, patient and demographic characteristics were retrieved from nationwide registries. MAIN OUTCOME MEASURES We used conditional logistic regression to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for epithelial ovarian cancer associated with antihistamine use (≥2 prescriptions). The association was evaluated according to patterns of antihistamine use, menopausal status, and histological subtype of ovarian cancer. RESULTS Ever use of antihistamines was not associated with ovarian cancer overall (OR = 0.97, 95% CI = 0.90-1.05). The lack of association remained in subanalyses for patterns of antihistamine use. We observed an inverse association between antihistamine use and ovarian cancer among pre-menopausal women (<50 year: OR = 0.72, 95% CI = 0.57-0.90), but not post-menopausal women (≥50 year: OR = 1.02, 95%CI = 0.93-1.11). In analyses of histological subtypes, an inverse association emerged for mucinous ovarian cancer (OR = 0.74, 95% CI = 0.57-0.96), but not for other subtypes. CONCLUSION Antihistamine use was not associated with overall ovarian cancer risk. Additional research is needed to confirm inverse associations between antihistamine use and mucinous ovarian cancer, and overall ovarian cancer among pre-menopausal women.
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Affiliation(s)
- Freija Verdoodt
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark.
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Christian Dehlendorff
- Unit of Statistics and Pharmacoepidemiology, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Marja Jäättelä
- Cell Death & Metabolism, Center for Autophagy, Recycling and Disease, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Søren Friis
- Unit of Statistics and Pharmacoepidemiology, Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Susanne K Kjaer
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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21
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Pottegård A, Hallas J, Wang SV, Gagne JJ. Identifying signals of interest when screening for drug-outcome associations in health care data. Br J Clin Pharmacol 2018; 84:1865-1867. [PMID: 29862551 DOI: 10.1111/bcp.13634] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/03/2018] [Accepted: 05/03/2018] [Indexed: 12/25/2022] Open
Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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22
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Wang SV, Kulldorff M, Glynn RJ, Gagne JJ, Pottegård A, Rothman KJ, Schneeweiss S, Walker AM. Reuse of data sources to evaluate drug safety signals: When is it appropriate? Pharmacoepidemiol Drug Saf 2018; 27:567-569. [PMID: 29701279 DOI: 10.1002/pds.4442] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Martin Kulldorff
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | | | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Hellfritzsch M, Rasmussen L, Hallas J, Pottegård A. Using the Symmetry Analysis Design to Screen for Adverse Effects of Non-vitamin K Antagonist Oral Anticoagulants. Drug Saf 2018; 41:685-695. [DOI: 10.1007/s40264-018-0650-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Pottegård A, Hallas J, Olesen M, Svendsen MT, Habel LA, Friedman GD, Friis S. Hydrochlorothiazide use is strongly associated with risk of lip cancer. J Intern Med 2017; 282:322-331. [PMID: 28480532 DOI: 10.1111/joim.12629] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The diuretic hydrochlorothiazide is amongst the most frequently prescribed drugs in the United States and Western Europe, but there is suggestive evidence that hydrochlorothiazide use increases the risk of lip cancer. OBJECTIVES To study the association between use of hydrochlorothiazide and squamous cell carcinoma of the lip. METHODS We conducted a case-control study using Danish nationwide registry data. From the Cancer Registry (2004-2012), we identified 633 case patients with squamous cell carcinoma (SCC) of the lip and matched them to 63 067 population controls using a risk-set sampling strategy. Hydrochlorothiazide use (1995-2012) was obtained from the Prescription Registry and defined according to cumulative use. Applying conditional logistic regression, we calculated odds ratios (ORs) for SCC lip cancer associated with hydrochlorothiazide use, adjusting for predefined potential confounders obtained from demographic, prescription and patient registries. RESULTS Ever-use of hydrochlorothiazide was associated with an adjusted OR for SCC lip cancer of 2.1 (95% confidence interval (CI): 1.7-2.6), increasing to 3.9 (95%CI: 3.0-4.9) for high use (≥25 000 mg). There was a clear dose-response effect (P < 0.001), with the highest cumulative dose category of hydrochlorothiazide (≥100 000 mg) presenting an OR of 7.7 (95%CI: 5.7-10.5). No association with lip cancer was seen with use of other diuretics or nondiuretic antihypertensives. Assuming causality, we estimated that 11% of the SCC lip cancer cases could be attributed to hydrochlorothiazide use. CONCLUSIONS Hydrochlorothiazide use is strongly associated with an increased risk of lip cancer.
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Affiliation(s)
- A Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - J Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - M Olesen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - M T Svendsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - L A Habel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - G D Friedman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - S Friis
- Danish Cancer Society, Danish Cancer Society Research Center, Copenhagen, Denmark
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Pottegård A, Hallas J. New use of prescription drugs prior to a cancer diagnosis. Pharmacoepidemiol Drug Saf 2016; 26:223-227. [PMID: 27889931 PMCID: PMC5299521 DOI: 10.1002/pds.4145] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/19/2016] [Accepted: 11/06/2016] [Indexed: 11/18/2022]
Abstract
Purpose Cancers often have considerable induction periods. This confers a risk of reverse causation bias in studies of cancer risk associated with drug use, as early symptoms of a yet undiagnosed cancer might lead to drug treatment in the period leading up to the diagnosis. This bias can be alleviated by disregarding exposure for some time before the cancer diagnosis (lag time). We aimed at assessing the duration of lag time needed to avoid reverse causation bias. Methods We identified all Danish patients with incident cancer between 2000 and 2012 (n = 353 087). Incident use of prescription drugs was assessed prior to their cancer diagnosis as well as among population controls (n = 1 402 400). Analyses were conducted for all cancers and for breast, lung, colon and prostate cancer individually. Further, analyses were performed for a composite measure of all incident drug use as well as for nine pre‐specified individual drug classes, representing drug treatment likely to be prescribed for symptoms of the given cancers. Results The incidence rate for new drug treatment among cancer cases was stable around 130 per 1000 persons per month until 6 months prior to cancer diagnosis where it increased gradually and peaked at 434 in the month immediately preceding the cancer diagnosis. Considerable variation was observed among cancers, for example, breast cancer showed almost no such effect. The pre‐selected drug classes showed a stronger increase prior to cancer diagnoses than drugs overall. Conclusions Incident use of drugs increases in the months prior to a cancer diagnosis. To avoid reverse causation, 6 months' lag time would be sufficient for most drug‐cancer associations. © 2016 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.
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Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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Time for integrating clinical, lifestyle and molecular data to predict drug responses - Authors' reply. EBioMedicine 2016; 7:11. [PMID: 27322447 PMCID: PMC4909323 DOI: 10.1016/j.ebiom.2016.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 12/03/2022] Open
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Patrignani P, Dovizio M. Time for Integrating Clinical, Lifestyle and Molecular Data to Predict Drug Responses. EBioMedicine 2016; 7:9-10. [PMID: 27322446 PMCID: PMC4909361 DOI: 10.1016/j.ebiom.2016.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/04/2016] [Indexed: 11/23/2022] Open
Affiliation(s)
- Paola Patrignani
- Department of Neuroscience, Imaging and Clinical Sciences and CeSI-MeT, "G. d'Annunzio" University, School of Medicine, Chieti, Italy.
| | - Melania Dovizio
- Department of Neuroscience, Imaging and Clinical Sciences and CeSI-MeT, "G. d'Annunzio" University, School of Medicine, Chieti, Italy
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