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Aikawa Y, Ogata S, Honda S, Nagai T, Murata S, Morii I, Anzai T, Nishimura K, Noguchi T. Prolonged delirium during hospitalization is associated with worse long-term and short-term outcomes in patients with acute heart failure. Int J Cardiol 2024; 399:131776. [PMID: 38216062 DOI: 10.1016/j.ijcard.2024.131776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND The association between prolonged delirium during hospitalization and long-term prognosis in patients with acute heart failure (AHF) admitted to the cardiac intensive care unit (CICU) has not been fully elucidated. METHODS We conducted a prospective registry study of patients with AHF admitted to the CICU at 2 hospitals from 2013 to 2021. We divided study patients into 3 groups according to the presence or absence of delirium and prolonged delirium as follows: no delirium, resolved delirium, or prolonged delirium. Main outcomes were in-hospital mortality and 3-year mortality after discharge. RESULTS A total of 1555 patients with AHF (median age, 80 years) were included in the analysis. Of these, 406 patients (26.1%) developed delirium. We divided patients with delirium into 2 groups: the resolved delirium group (n = 201) or the prolonged delirium group (n = 205). Multivariate Cox proportional hazards models for long-term prognosis demonstrated that the prolonged delirium group had a higher incidence of all-cause death (hazard ratio [HR], 1.52; 95% CI, 1.08 to 2.14) and non-cardiovascular death (HR, 1.84; 95% CI, 1.21 to 2.78) than the resolved delirium group. Regarding in-hospital outcomes, multivariate logistic regression modeling showed that prolonged delirium is associated with all-cause death (odds ratio [OR], 9.55; 95% confidential interval [CI], 2.99 to 30.53) and cardiovascular death (OR, 13.02; 95% CI, 2.86 to 59.27) compared with resolved delirium. CONCLUSIONS Prolonged delirium is associated with worse long-term and short-term outcomes than resolved delirium in patients with AHF.
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Affiliation(s)
- Yukio Aikawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiology, Hokusetsu General Hospital, Takatsuki, Japan.
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shunsuke Murata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Isao Morii
- Department of Cardiology, Hokusetsu General Hospital, Takatsuki, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Parish O, Cannata A, Shamsi A, Jordan-Rios A, Albarjas M, Piper S, Scott P, Bromage D, McDonagh T. Prognostic Role of Contraindicated Drugs in Hospitalized Patients with Decompensated Heart Failure. J Pharmacol Exp Ther 2023; 386:205-211. [PMID: 37164369 DOI: 10.1124/jpet.122.001413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 03/24/2023] [Accepted: 04/05/2023] [Indexed: 05/12/2023] Open
Abstract
Due to the ageing population, patients often present to the hospital with a high burden of comorbidities and polypharmacy. For patients admitted with decompensated heart failure (HF), the evidence on the effects of contraindicated drugs on long-term mortality is scarce. Therefore, we aimed to investigate the effect of contraindicated medications on outcomes of patients admitted with decompensated HF. We analyzed all consecutive patients from the National Heart Failure Audit admitted to two tertiary centers with acutely decompensated HF between April 2020 and October 2021. We included medication classes listed as contraindicated (class III) in the most recent European and American guidelines on the management of HF. The primary outcome measure was in-hospital mortality. The secondary outcome measure was overall mortality. Overall, 716 patients admitted with acute HF were included. One-fifth (n = 156, 21.8%) were on at least one contraindicated medication at admission. The prevalence of comorbidities was comparable between medication groups. During hospitalization, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with increased in-hospital mortality (29% versus 9%, P = 0.013). On multivariable analyses, NSAID use was independently associated with worse in-hospital mortality (hazard ratio, 6.86; 95% confidence interval, 1.61-25.5; P = 0.005). However, other contraindicated medications were not associated with adverse outcomes. Postdischarge, the use of erythropoietin during admission was associated with increased mortality (54% versus 31%, P = 0.031). NSAID use is associated with increased in-hospital mortality for patients admitted with acute HF. However, inpatient use of other contraindicated medications was not associated with adverse in-hospital outcomes. Further studies are needed to confirm these results in larger and prospective cohorts. SIGNIFICANCE STATEMENT: Use of nonsteroidal anti-inflammatory drugs is associated with a worse in-hospital mortality in patients with decompensated heart failure. The prognostic role of other contraindicated medications remains still uncertain.
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Affiliation(s)
- Olivia Parish
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
| | - Antonio Cannata
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
| | - Aamir Shamsi
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
| | - Antonio Jordan-Rios
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
| | - Mohammad Albarjas
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
| | - Susan Piper
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
| | - Paul Scott
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
| | - Daniel Bromage
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
| | - Theresa McDonagh
- Department of Cardiology, King's College Hospital, London, United Kingdom (O.P., A.C., A.S., A.J.-R., S.P., P.S., D.B., T.M.) and Department of Cardiology, Princess Royal University Hospital, London, United Kingdom (M.A.)
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Holt A, Strange JE, Nouhravesh N, Nielsen SK, Malik ME, Schjerning AM, Køber L, Torp-Pedersen C, Gislason GH, McGettigan P, Schou M, Lamberts M. Heart Failure Following Anti-Inflammatory Medications in Patients With Type 2 Diabetes Mellitus. J Am Coll Cardiol 2023; 81:1459-1470. [PMID: 37045515 DOI: 10.1016/j.jacc.2023.02.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Fluid retention and endothelial dysfunction have been related to use of nonsteroidal anti-inflammatory drugs (NSAIDs), and type 2 diabetes mellitus (T2DM) has been linked to both a decline in kidney function and subclinical cardiomyopathy. OBJECTIVES The authors hypothesized that short-term use of NSAIDs could lead to subsequent development of incident heart failure (HF) in patients with T2DM. METHODS Using nationwide Danish registers, we identified patients diagnosed with T2DM during 1998 to 2021 and included patients without previous HF, rheumatic disease, or use of NSAIDs 120 days before diagnosis. Associations between NSAIDs and first-time HF hospitalization were investigated using a case-crossover design with 28-day exposure windows, and ORs with 95% CIs were reported. RESULTS Included were 331,189 patients with T2DM: 44.2% female, median age of 62 years (IQR: 52-71 years); 23,308 patients were hospitalized with HF during follow-up, and 16% of patients claimed at least 1 NSAID prescription within 1 year. Short-term use of NSAIDs was associated with increased risk of HF hospitalization (OR: 1.43; 95% CI: 1.27-1.63), most notably in subgroups with age ≥80 years (OR: 1.78; 95% CI: 1.39-2.28), elevated hemoglobin (Hb) A1c levels treated with 0 to 1 antidiabetic drug (OR: 1.68; 95% CI: 1.00-2.88), and without previous use of NSAIDs (OR: 2.71; 95% CI: 1.78-4.23). CONCLUSIONS NSAIDs were widely used and were associated with an increased risk of first-time HF hospitalization in patients with T2DM. Patients with advanced age, elevated HbA1c levels, and new users of NSAID seemed more susceptible. These findings could guide physicians prescribing NSAIDs.
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Affiliation(s)
- Anders Holt
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej, Hellerup, Denmark; Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Grafton, Auckland, New Zealand.
| | - Jarl E Strange
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej, Hellerup, Denmark; Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark. https://twitter.com/JarlStrange
| | - Nina Nouhravesh
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej, Hellerup, Denmark. https://twitter.com/NinaNouhravesh
| | - Sebastian Kinnberg Nielsen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej, Hellerup, Denmark. https://twitter.com/SebKinnberg
| | - Mariam Elmegaard Malik
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej, Hellerup, Denmark. https://twitter.com/MariamElmegaard
| | - Anne-Marie Schjerning
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark; The Danish Heart Foundation, Copenhagen, Denmark. https://twitter.com/AnneSchjerning
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark; Department of Public Health, University of Copenhagen, Copenhagen, Denmark. https://twitter.com/PedersenTorp
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej, Hellerup, Denmark; The Danish Heart Foundation, Copenhagen, Denmark; Department of Public Health, University of Copenhagen, Copenhagen, Denmark; National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark. https://twitter.com/gunngis
| | - Patricia McGettigan
- William Harvey Research Institute, Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom. https://twitter.com/P_McGettigan
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej, Hellerup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark. https://twitter.com/mortschou
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej, Hellerup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark. https://twitter.com/MortenLamberts
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4
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Stiller CO, Hjemdahl P. Lessons from 20 years with COX-2 inhibitors: Importance of dose-response considerations and fair play in comparative trials. J Intern Med 2022; 292:557-574. [PMID: 35585779 DOI: 10.1111/joim.13505] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the enzyme cyclooxygenase (COX), which forms prostaglandins involved in pain and inflammation. COX inhibitors have analgesic and anti-inflammatory effects, but also increase risks for gastrointestinal ulcers, bleeding, and renal and cardiovascular adverse events. Identification of two isoforms of COX, COX-1 and COX-2, led to the development of selective COX-2 inhibitors, which were launched as having fewer gastrointestinal side effects since gastroprotective prostaglandins produced via COX-1 are spared. The balance between COX-1 mediated prothrombotic thromboxane and COX-2 mediated antithrombotic prostacyclin is important for thrombotic risk. An increased risk of suffering myocardial infarction and death with COX-2 inhibitor treatment is well established from clinical trials and observational research. Rofecoxib (Vioxx) was withdrawn from the market for this reason, but the equally COX-2 selective etoricoxib has replaced it in Europe but not in the United States. The "traditional" NSAID diclofenac is as COX-2 selective as celecoxib and increases cardiovascular risk dose dependently. COX inhibitor dosages should be lower in osteoarthritis than in rheumatoid arthritis. Randomized trials comparing COX-2 inhibitors with NSAIDs have exaggerated their gastrointestinal benefits by using maximal NSAID doses regardless of indication, and/or hidden the cardiovascular risk by comparing with COX-2 selective diclofenac instead of low-dose ibuprofen or naproxen. Observational studies show increased cardiovascular risks within weeks of treatment with COX-2 inhibitors and high doses of NSAIDs other than naproxen, which is the safest alternative. COX inhibitors are symptomatic drugs that should be used intermittently at the lowest effective dosage, especially among individuals with an increased cardiovascular risk.
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Affiliation(s)
- Carl-Olav Stiller
- Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet and Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet and Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
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5
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Cardiovascular Risks of Diclofenac Versus Other Older COX-2 Inhibitors (Meloxicam and Etodolac) and Newer COX-2 Inhibitors (Celecoxib and Etoricoxib): A Series of Nationwide Emulated Trials. Drug Saf 2022; 45:983-994. [PMID: 35909207 DOI: 10.1007/s40264-022-01211-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Diclofenac has increased cardiovascular risks, but its risk profile compared with other COX-2 inhibitors remains unknown. AIMS The aim of this study was to compare the cardiovascular risks of diclofenac versus other older and newer COX-2 inhibitors (coxibs). METHODS Using Danish nationwide health registries (1999-2020), we conducted a series of emulated trials (n = 264). Eligible adults had no recent NSAID prescriptions, contraindications or conditions with low adherence. We included initiators of diclofenac (n = 1,600,202), meloxicam (n = 10,903), etodolac (n = 238,538), celecoxib (n = 77,591), and etoricoxib (n = 12,122). We computed the adjusted intention-to-treat incidence rate ratio (aIRR) with 95% confidence interval (CI) of major adverse cardiovascular events (MACE) within 30 days of initiation (5562 events). RESULTS MACE was 20% increased among initiators of diclofenac compared with other older COX-2 inhibitors (aIRR 1.19, 95% CI 1.10-1.28), driven by cardiac death (aIRR 1.57, 95% CI 1.21-2.03). The effect appeared strongest for women (aIRR 1.28, 95% CI 1.15-1.43), individuals with high baseline cardiovascular risk (aIRR 1.32, 95% CI 1.05-1.66), and when comparing high-dose diclofenac with low doses of the other older COX-2 inhibitors (aIRR 1.31, 95% CI 1.13-1.52). The results reflected increased rates compared with both meloxicam (aIRR 1.46, 95% CI 0.94-2.26) and etodolac (aIRR 1.18, 95% CI 1.09-1.28). Diclofenac initiators had similar increased rates of MACE compared with coxibs (aIRR 0.96, 95% CI 0.85-1.08), consistent for celecoxib (aIRR 1.02, 95% CI 0.88-1.19) and etoricoxib (aIRR 0.85, 95% CI 0.66-1.10). CONCLUSIONS The increased cardiovascular risks associated with diclofenac initiation were higher than for other older COX-2 inhibitors (meloxicam/etodolac) and comparable to coxibs (celecoxib/etoricoxib).
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Hu S, Yang M, Huang S, Zhong S, Zhang Q, Ding H, Xiong X, Hu Z, Yang Y. Different Roles of Resident and Non-resident Macrophages in Cardiac Fibrosis. Front Cardiovasc Med 2022; 9:818188. [PMID: 35330948 PMCID: PMC8940216 DOI: 10.3389/fcvm.2022.818188] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/17/2022] [Indexed: 12/21/2022] Open
Abstract
Cardiac fibrosis is a key pathological link of various cardiovascular diseases to heart failure. It is of great significance to deeply understand the development process of cardiac fibrosis and the cellular and molecular mechanisms involved. Macrophages play a special role in promoting heart development, maintaining myocardial cell homeostasis and heart function. They are involved in the whole process from inflammatory to cardiac fibrosis. This article summarizes the relationship between inflammation and fibrosis, discusses the bidirectional regulation of cardiac fibrosis by macrophages and analyses the functional heterogeneity of macrophages from different sources. It is believed that CCR2– cardiac resident macrophages can promote cardiac function, but the recruitment and infiltration of CCR2+ cardiac non-resident macrophages aggravate cardiac dysfunction and heart remodeling. After heart injury, damage associated molecular patterns (DAMPs) are released in large quantities, and the inflammatory signal mediated by macrophage chemoattractant protein-1 (MCP-1) promotes the infiltration of CCR2+ monocytes and transforms into macrophages in the heart. These CCR2+ non-resident macrophages not only replace part of the CCR2– resident macrophage subpopulation in the heart, but also cause cardiac homeostasis and hypofunction, and release a large number of mediators that promote fibroblast activation to cause cardiac fibrosis. This article reveals the cell biology mechanism of resident and non-resident macrophages in regulating cardiac fibrosis. It is believed that inhibiting the infiltration of cardiac non-resident macrophages and promoting the proliferation and activation of cardiac resident macrophages are the key to improving cardiac fibrosis and improving cardiac function.
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Affiliation(s)
- Siyuan Hu
- School of Sports Art, Hunan University of Chinese Medicine, Changsha, China.,College of Health Science, Wuhan Sports University, Wuhan, China
| | - Meng Yang
- Institute of Chinese Medicine Diagnosis, Hunan University of Chinese Medicine, Changsha, China.,Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Shumin Huang
- Institute of Chinese Medicine Diagnosis, Hunan University of Chinese Medicine, Changsha, China.,Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Senjie Zhong
- Institute of Chinese Medicine Diagnosis, Hunan University of Chinese Medicine, Changsha, China.,Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Qian Zhang
- Institute of Chinese Medicine Diagnosis, Hunan University of Chinese Medicine, Changsha, China.,Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Haichao Ding
- College of Health Science, Wuhan Sports University, Wuhan, China
| | - Xiajun Xiong
- Institute of Chinese Medicine Diagnosis, Hunan University of Chinese Medicine, Changsha, China.,Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Zhixi Hu
- Institute of Chinese Medicine Diagnosis, Hunan University of Chinese Medicine, Changsha, China
| | - Yi Yang
- College of Health Science, Wuhan Sports University, Wuhan, China
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7
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Comment on "Perioperative Nonsteroidal Anti-inflammatory Drugs (NSAID) Administration and Acute Kidney Injury (AKI) in Major Gastrointestinal Surgery". Ann Surg 2021; 274:e875-e876. [PMID: 33630428 DOI: 10.1097/sla.0000000000004823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Sareen N, Srivastava A, Dhingra S. Role of prostaglandin E2 in allogeneic mesenchymal stem cell therapy for cardiac repair. Can J Physiol Pharmacol 2021; 99:140-150. [PMID: 33559528 DOI: 10.1139/cjpp-2020-0413] [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] [Indexed: 11/22/2022]
Abstract
Ischemic heart disease is among the primary causes of cardiovascular-related deaths worldwide. Conventional treatments including surgical interventions and medical therapies aid in preventing further damage to heart muscle but are unable to provide a permanent solution. In recent years, stem cell therapy has emerged as an attractive alternative to restore damaged myocardium after myocardial injury. Allogeneic (donor-derived) mesenchymal stem cells (MSCs) have shown great promise in preclinical and clinical studies, making them the most widely accepted candidates for cardiac cell therapy. MSCs promote cardiac repair by modulating host immune system and secreting various soluble factors, of which prostaglandin E2 (PGE2) is an important one. PGE2 plays a significant role in regulating cardiac remodeling following myocardial injury. In this review, we provide an overview of allogeneic MSCs as candidates for myocardial regeneration with a focus on the role of the PGE2/cyclooxygenase-2 (COX2) pathway in mediating these effects.
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Affiliation(s)
- Niketa Sareen
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Abhay Srivastava
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sanjiv Dhingra
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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9
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El Hadidi S, Rosano G, Tamargo J, Agewall S, Drexel H, Kaski JC, Niessner A, Lewis BS, Coats AJS. Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:187-210. [PMID: 32941594 DOI: 10.1093/ehjcvp/pvaa108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/12/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022]
Abstract
Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.
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Affiliation(s)
- Seif El Hadidi
- Faculty of Pharmaceutical Sciences and Pharmaceutical Industries, Future University in Egypt, New Cairo, Egypt
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy.,Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, Madrid, Spain
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Heinz Drexel
- VIVIT Institute, Landeskrankenhaus Feldkirch, Austria
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
| | - Andrew J S Coats
- Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy
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10
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Huang W, Lee SGS, How CH. Management of the heart failure patient in the primary care setting. Singapore Med J 2020; 61:225-229. [PMID: 32754766 DOI: 10.11622/smedj.2020073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Weiliang Huang
- Department of Cardiology, Changi General Hospital, Singapore
| | | | - Choon How How
- Care and Health Integration, Changi General Hospital, Singapore.,Family Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
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11
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Alvarez PA, Gao Y, Girotra S, Mentias A, Briasoulis A, Vaughan Sarrazin MS. Potentially harmful drug prescription in elderly patients with heart failure with reduced ejection fraction. ESC Heart Fail 2020; 7:1862-1871. [PMID: 32419388 PMCID: PMC7373931 DOI: 10.1002/ehf2.12752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/22/2020] [Accepted: 04/26/2020] [Indexed: 01/08/2023] Open
Abstract
Aims This study aimed to evaluate the prescription frequency of potentially harmful prescription drugs as defined in current heart failure guidelines among elderly patients with a diagnosis of heart failure with reduced ejection fraction and their association with clinical outcomes. Methods and results We used the Centers for Medicare & Medicaid Services data from a nationally representative 5% sample for the years 2014–2016 to identify patients admitted to acute care hospitals with a primary diagnosis of heart failure with reduced ejection fraction. The primary exposure was filling a prescription for a potentially harmful drug. Potentially harmful drug fills were treated as a time‐dependent covariate to examine their association on readmission and mortality. A total of 8993 patients met study criteria. Potentially harmful drugs were prescribed in 1077 (11.9%) patients within 90 days of discharge from the heart failure hospitalization. Non‐steroidal anti‐inflammatory agents were the most frequently prescribed potentially harmful drug (6.7%) followed by calcium channel blockers (4.7%), thiazolidinedione (0.59%), and select antiarrhythmic (0.33%). Factors independently associated with potentially harmful drug prescription were female gender, Hispanic ethnicity, severe obesity, among others. In the multivariable Cox model, the prescription of a potentially harmful drug was associated with an increased risk of readmission (hazard ratio 1.14; 95% confidence interval 1.05–1.23, P < 0.001). Among drug subgroups, only calcium channel blockers were associated with an increased risk of readmission (hazard ratio 1.225; 95% confidence interval 1.085–1.382, P = 0.0011). Conclusions In elderly patients discharged with a primary diagnosis of heart failure with reduced ejection fraction on guideline‐directed medical therapy, prescription of a potentially harmful drug was frequent. Calcium channel blockers were associated with an increased risk of readmission.
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Affiliation(s)
- Paulino A Alvarez
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Yubo Gao
- Institute for Clinical and Translational Sciences, University of Iowa, 200 Hawkins Drive, C44-GH, Iowa City, IA, 52242, USA
| | - Saket Girotra
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Amgad Mentias
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Alexandros Briasoulis
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Mary S Vaughan Sarrazin
- Institute for Clinical and Translational Sciences, University of Iowa, 200 Hawkins Drive, C44-GH, Iowa City, IA, 52242, USA
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12
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Szeto CC, Sugano K, Wang JG, Fujimoto K, Whittle S, Modi GK, Chen CH, Park JB, Tam LS, Vareesangthip K, Tsoi KKF, Chan FKL. Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut 2020; 69:617-629. [PMID: 31937550 DOI: 10.1136/gutjnl-2019-319300] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/06/2019] [Accepted: 12/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications. OBJECTIVE To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs. METHODS Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations. RESULTS Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases. CONCLUSION NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong
| | - Kentaro Sugano
- Jichi Medical University, Shimotsuke, Tochigi, Japan.,Asian Pacific Association of Gastroenterology (APAGE), Tochigi, Japan
| | - Ji-Guang Wang
- Shanghai Institute of Hypertension, Shanghai, Shanghai, China.,Asia Pacific Society of Hypertension (APSH), Shanghai, China
| | - Kazuma Fujimoto
- Saga University, Saga, Japan.,Asia-Pacific Society for Digestive Endoscopy (APSDE), Saga, Japan
| | - Samuel Whittle
- The University of Adelaide, Adelaide, South Australia, Australia.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Gopesh K Modi
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Samarpan Kidney Institute and Research Center, Bhopal, India
| | - Chen-Huen Chen
- National Yang-Ming University, Taipei, Taiwan.,Pulse of Asia (PoA), Taipei, Taiwan
| | - Jeong-Bae Park
- Pulse of Asia (PoA), Taipei, Taiwan.,JB Lab and Clinic and Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Kriengsak Vareesangthip
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Mahidol University, Nakorn Pathom, Thailand
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13
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Abstract
Heart failure with preserved ejection fraction is a highly heterogenous disease. There is emerging evidence that treatment should be tailored to the individual’s associated comorbidities No current algorithms exist for the management of heart failure with preserved ejection fraction. Conventional therapies used in heart failure with reduced ejection fraction are yet to show a mortality benefit Key treatment objectives include control of hypertension and fluid balance Common comorbidities include coronary artery disease, atrial fibrillation, obesity, diabetes, renal impairment and pulmonary hypertension. These comorbidities should be considered in all patients and treatment optimised
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Affiliation(s)
- Emma Gard
- Monash University, Clayton, Vic.,Department of Cardiology, Alfred Health, Melbourne.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne.,National Health and Medical Research Council, Canberra
| | - Shane Nanayakkara
- Monash University, Clayton, Vic.,Department of Cardiology, Alfred Health, Melbourne.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne.,National Health and Medical Research Council, Canberra
| | - David Kaye
- Monash University, Clayton, Vic.,Department of Cardiology, Alfred Health, Melbourne.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne.,National Health and Medical Research Council, Canberra
| | - Harry Gibbs
- Monash University, Clayton, Vic.,Department of Cardiology, Alfred Health, Melbourne.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne.,National Health and Medical Research Council, Canberra
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14
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Lee JO, Kim JH, Kim S, Kim MY, Hong YH, Kim HG, Cho JY. Gastroprotective effects of the nonsaponin fraction of Korean Red Ginseng through cyclooxygenase-1 upregulation. J Ginseng Res 2019; 44:655-663. [PMID: 32617046 PMCID: PMC7322762 DOI: 10.1016/j.jgr.2019.11.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 10/07/2019] [Accepted: 11/01/2019] [Indexed: 01/16/2023] Open
Abstract
Background Korean Red Ginseng is known to exhibit immune-enhancing and anti-inflammatory properties. The immune-enhancing effects of the nonsaponin fraction (NSF) of Korean Red Ginseng have been studied in many reports. However, the gastroprotective effect of this fraction is not fully understood. In this study, we demonstrate the activities of NSF for gastrointestinal protection and its related critical factor. Methods The in vitro and in vivo regulatory functions of NSF on cyclooxygenase-1 (COX-1) messenger RNA and protein levels were examined by reverse transcription polymerase chain reaction and immunoblotting analyses. Gastroprotective effects of NSF were investigated by histological score, gastric juice pH, and myeloperoxidase activity on indomethacin-induced, cold stress-induced, and acetylsalicylic acid-induced gastritis and dextran sulfate sodium-induced colitis in in vivo mouse models. Results NSF did not show cytotoxicity, and it increased COX-1 messenger RNA expression and protein levels in RAW264.7 cells. This upregulation was also observed in colitis and gastritis in vivo models. In addition, NSF treatment in mice ameliorated the symptoms of gastrointestinal inflammation, including histological score, colon length, gastric juice pH, gastric wall thickness, and myeloperoxidase activity. Conclusion These results suggest that NSF has gastroprotective effects on gastritis and colitis in in vivo mouse models through COX-1 upregulation.
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Affiliation(s)
- Jeong-Oog Lee
- Department of Aerospace Information Engineering, Bio-Inspired Aerospace Information Laboratory, Konkuk University, Seoul, Republic of Korea
| | - Ji Hye Kim
- Department of Integrative Biotechnology, Sungkyunkwan University, Suwon, Republic of Korea
| | - Sunggyu Kim
- Research and Business Foundation, Sungkyunkwan University, Suwon, Republic of Korea
- Department of Biocosmetics, Sungkyunkwan University, Suwon, Republic of Korea
| | - Mi-Yeon Kim
- School of Systems Biomedical Science, Soongsil University, Seoul, Republic of Korea
| | - Yo Han Hong
- Department of Integrative Biotechnology, Sungkyunkwan University, Suwon, Republic of Korea
- Corresponding author: Department of Integrative Biotechnology, Sungkyunkwan University, 2066 Seobu-ro, Suwon, 16419, Republic of Korea.
| | - Han Gyung Kim
- Department of Integrative Biotechnology, Sungkyunkwan University, Suwon, Republic of Korea
- Corresponding author: Department of Integrative Biotechnology, Sungkyunkwan University, 2066 Seobu-ro, Suwon 16419, Republic of Korea.
| | - Jae Youl Cho
- Department of Integrative Biotechnology, Sungkyunkwan University, Suwon, Republic of Korea
- Research and Business Foundation, Sungkyunkwan University, Suwon, Republic of Korea
- Corresponding author: Department of Integrative Biotechnology, Sungkyunkwan University, 2066 Seobu-ro, Suwon, 16419, Republic of Korea.
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15
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Cabassi A, Tedeschi S, Perlini S, Verzicco I, Volpi R, Gonzi G, Canale SD. Non-steroidal anti-inflammatory drug effects on renal and cardiovascular function: from physiology to clinical practice. Eur J Prev Cardiol 2019; 27:850-867. [PMID: 31088130 DOI: 10.1177/2047487319848105] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Excessive or inappropriate use of non-steroidal anti-inflammatory drugs can affect cardiovascular and renal function. Non-steroidal anti-inflammatory drugs, both non-selective and selective cyclooxygenase 2 inhibitors, are among the most widely used drugs, especially in the elderly, with multiple comorbidities. Exposition to a polypharmacy burden represents a favourable substrate for the onset of non-steroidal anti-inflammatory drug-induced deleterious effects. Cardiovascular and renal issues concerning the occurrence of myocardial infarction, atrial fibrillation, heart failure and arterial hypertension, as well as acute or chronic kidney damage, become critical for clinicians in their daily practice. We discuss current available knowledge regarding prostanoid physiology in vascular, cardiac and renal systems, pointing out potential negative non-steroidal anti-inflammatory drug-related issues in clinical practice.
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Affiliation(s)
| | - Stefano Tedeschi
- Cardiorenal Research Unit, University of Parma, Parma, Italy.,Cardiology Unit, Ospedale Vaio, Vaio-Fidenza, Parma, Italy
| | - Stefano Perlini
- Unità di Medicina Interna, Università di Pavia, Vaio-Fidenza, Parma, Italy
| | | | - Riccardo Volpi
- Cardiorenal Research Unit, University of Parma, Parma, Italy
| | - Gianluca Gonzi
- Cardiology Unit, Azienda Ospedaliera-Universitaria di Parma, Italy
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16
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Iglesias J, Ghetiya S, Ledesma KJ, Patel CS, Levine JS. Interactive and potentially independent roles of renin-angiotensin-aldosterone system blockade and the development of cardiorenal syndrome type 1 on in-hospital mortality among elderly patients admitted with acute decompensated congestive heart failure. Int J Nephrol Renovasc Dis 2019; 12:33-48. [PMID: 30936736 PMCID: PMC6421894 DOI: 10.2147/ijnrd.s185988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Cardiorenal syndrome type 1 (CRS1), defined as worsening renal function from acute decompensated congestive heart failure (ADCHF), is complicated by the fact that CRS1 limits the use of common therapeutic strategies, such as angiotensin converting-enzyme inhibitors (ACEIs) or angiotensin II-receptor blockers (A2RB). The present study examines retrospectively the role of ACEI/A2RB usage on in-hospital mortality among elderly ADCHF patients, in particular those who developed CRS1. Methods We retrospectively examined the effects of ACEI/A2RB usage and CRS1 development (in-hospital change in serum creatinine ≥0.3 mg/dL or ≥0.5 mg/dL), as well as their potential interaction, on in-hospital mortality among elderly ADCHF patients (aged ≥65 years). Employing univariate and multivariate analyses, we performed risk-factor analysis on a cohort of 419 patients (51 nonsurvivors [12.2%]) for whom we had complete clinical and laboratory data (median follow-up 5 days) from 2,361 consecutive elderly ADCHF patients (106 nonsurvivors [4.6%]). Results By multivariate analysis, the two strongest independent predictors of in-hospital mortality were CRS1 development (OR 7.8, 95% CI 3.9–15.5; P=0.00001) and lack of ACEI/A2RB usage (OR 0.49, CI 0.25–0.93; P=0.043). The effect of CRS1 was graded, with increasing CRS1 severity associated with increased mortality. On multivariate subgroup analysis, the association between lack of ACEI/A2RB usage and increased mortality remained a significant independent predictor among patients not developing CRS1 (OR 0.24, CI 0.083–0.721; P=0.011). Conclusion Our data suggest that development of CRS1 and lack of ACEI/A2RB usage are statistically independent predictors of in-hospital mortality for elderly ADCHF patients, with CRS1 being the stronger of the two risk factors. While it remains unclear whether lack of ACEI/ A2RB usage is causally related to increased mortality or reflects another risk factor inducing physicians to forego ACEIs/A2RBs, our findings nevertheless indicate the need to address this issue in future prospective studies.
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Affiliation(s)
- Jose Iglesias
- Department of Medicine, Subsection of Nephrology, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA, .,Department of Medicine, Subsection of Nephrology, Jersey Shore University Medical Center, Neptune, NJ, USA, .,Department of Medicine Section of Nephrology, Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA, .,Department of Medicine, Subsection of Nephrology, RWJ Barnabas Health Community Medical Center, Toms River, NJ, USA,
| | - Savan Ghetiya
- Department of Medicine, Coney Island University Medical Center, New York, NY, USA
| | - Kandria J Ledesma
- American University of Antigua College of Medicine, Coolidge, Antigua and Barbuda
| | - Chirag S Patel
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Jerrold S Levine
- Department of Medicine, Section of Nephrology, University of Illinois at Chicago, Chicago, IL, USA.,Department of Medicine Section of Nephrology, Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA
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17
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Abstract
OBJECTIVE To examine the cardiovascular risks of diclofenac initiation compared with initiation of other traditional non-steroidal anti-inflammatory drugs, initiation of paracetamol, and no initiation. DESIGN Series of 252 nationwide cohort studies, each mimicking the strict design criteria of a clinical trial (emulated trial design). SETTING Danish, nationwide, population based health registries (1996-2016). PARTICIPANTS Individuals eligible for inclusion were all adults without malignancy; schizophrenia; dementia; or cardiovascular, kidney, liver, or ulcer diseases (that is, with low baseline risk). The study included 1 370 832 diclofenac initiators, 3 878 454 ibuprofen initiators, 291 490 naproxen initiators, 764 781 healthcare seeking paracetamol initiators matched by propensity score, and 1 303 209 healthcare seeking non-initiators also matched by propensity score. MAIN OUTCOME MEASURES Cox proportional hazards regression was used to compute the intention to treat hazard ratio (as a measure of the incidence rate ratio) of major adverse cardiovascular events within 30 days of initiation. RESULTS The adverse event rate among diclofenac initiators increased by 50% compared with non-initiators (incidence rate ratio 1.5, 95% confidence interval 1.4 to 1.7), 20% compared with paracetamol or ibuprofen initiators (both 1.2, 1.1 to 1.3), and 30% compared with naproxen initiators (1.3, 1.1 to 1.5). The event rate for diclofenac initiators increased for each component of the combined endpoint (1.2 (1.1 to 1.4) for atrial fibrillation/flutter, 1.6 (1.3 to 2.0) for ischaemic stroke, 1.7 (1.4 to 2.0) for heart failure, 1.9 (1.6 to 2.2) for myocardial infarction, and 1.7 (1.4 to 2.1) for cardiac death) as well as for low doses of diclofenac, compared with non-initiators. Although the relative risk of major adverse cardiovascular events was highest in individuals with low or moderate baseline risk (that is, diabetes mellitus), the absolute risk was highest in individuals with high baseline risk (that is, previous myocardial infarction or heart failure). Diclofenac initiation also increased the risk of upper gastrointestinal bleeding at 30 days, by approximately 4.5-fold compared with no initiation, 2.5-fold compared with initiation of ibuprofen or paracetamol, and to a similar extent as naproxen initiation. CONCLUSIONS Diclofenac poses a cardiovascular health risk compared with non-use, paracetamol use, and use of other traditional non-steroidal anti-inflammatory drugs.
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Affiliation(s)
- Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus, Denmark
- Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus, Denmark
- Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, CA, USA
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus, Denmark
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19
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Bloom MW, Greenberg B, Jaarsma T, Januzzi JL, Lam CSP, Maggioni AP, Trochu JN, Butler J. Heart failure with reduced ejection fraction. Nat Rev Dis Primers 2017; 3:17058. [PMID: 28836616 DOI: 10.1038/nrdp.2017.58] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Heart failure is a global public health problem that affects more than 26 million people worldwide. The global burden of heart failure is growing and is expected to increase substantially with the ageing of the population. Heart failure with reduced ejection fraction accounts for approximately 50% of all cases of heart failure in the United States and is associated with substantial morbidity and reduced quality of life. Several diseases, such as myocardial infarction, certain infectious diseases and endocrine disorders, can initiate a primary pathophysiological process that can lead to reduced ventricular function and to heart failure. Initially, ventricular impairment is compensated for by the activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system, but chronic activation of these pathways leads to worsening cardiac function. The symptoms of heart failure can be associated with other conditions and include dyspnoea, fatigue, limitations in exercise tolerance and fluid accumulation, which can make diagnosis difficult. Management strategies include the use of pharmacological therapies and implantable devices to regulate cardiac function. Despite these available treatments, heart failure remains incurable, and patients have a poor prognosis and high mortality rate. Consequently, the development of new therapies is imperative and requires further research.
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Affiliation(s)
- Michelle W Bloom
- Division of Cardiology, Stony Brook University Medical Center, 101 Nicolls Road, HSC, T-16, Rm 080, Stony Brook, New York 11794-8167, USA
| | - Barry Greenberg
- Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, California, USA
| | - Tiny Jaarsma
- Faculty of Medicine and Health Sciences, Linkoping University, Linkoping, Sweden.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Carolyn S P Lam
- Department of Cardiology, National Heart Centre Singapore, Singapore.,Programme in Cardiovascular and Metabolic Disorders, Duke-National University of Singapore Medical School, Singapore
| | - Aldo P Maggioni
- Italian Association of Hospital Cardiologists (ANMCO) Research Center, Florence, Italy
| | - Jean-Noël Trochu
- l'institut du thorax, Centre Hospital-Universitaire de Nantes, Nantes, France.,Medical School, University of Nantes, Nantes, France.,INSERM UMR1087 and CIC 1413, Nantes, France
| | - Javed Butler
- Division of Cardiology, Stony Brook University Medical Center, 101 Nicolls Road, HSC, T-16, Rm 080, Stony Brook, New York 11794-8167, USA
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20
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Alvarez PA, Nguyen DT, Schutt R, Ganduglia C, Estep JD, Graviss EA, Putney D. In-hospital use of non-steroidal anti-inflammatory drugs in patients with heart failure in academic centers in the United States. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2017; 28:181-188. [DOI: 10.3233/jrs-170736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paulino A. Alvarez
- Department of Cardiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Duc T. Nguyen
- Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Robert Schutt
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jerry D. Estep
- Department of Cardiology, Houston Methodist Hospital, Houston, TX, USA
| | | | - David Putney
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
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21
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NSAID Use and Cardiovascular Disease - A Cautionary Tale. Heart Lung Circ 2017; 26:753-756. [PMID: 28601533 DOI: 10.1016/j.hlc.2017.05.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 05/02/2017] [Indexed: 11/22/2022]
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22
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Cardiovascular Safety and Bleeding Risk Associated with Nonsteroidal Anti-Inflammatory Medications in Patients with Cardiovascular Disease. Curr Cardiol Rep 2017; 19:8. [PMID: 28138824 DOI: 10.1007/s11886-017-0814-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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23
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Silvestre OM, Gonçalves A, Nadruz W, Claggett B, Couper D, Eckfeldt JH, Pankow JS, Anker SD, Solomon SD. Ferritin levels and risk of heart failure-the Atherosclerosis Risk in Communities Study. Eur J Heart Fail 2016; 19:340-347. [PMID: 27976478 DOI: 10.1002/ejhf.701] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/22/2016] [Accepted: 10/09/2016] [Indexed: 12/17/2022] Open
Abstract
AIMS Severe iron overload is associated with cardiac damage, while iron deficiency has been related to worse outcomes in subjects with heart failure (HF). This study investigated the relationship between ferritin, a marker of iron status, and the incidence of HF in a community-based cohort. METHODS AND RESULTS We examined 1063 participants who were free of heart failure from the Atherosclerosis Risk in Communities (ARIC) Study in whom ferritin serum levels were measured at baseline (1987-1989). The participants (mean age 52.7 ± 5.5 years, 62% women), were categorized in low (<30 ng/mL; n = 153), normal (30-200 ng/mL in women and 30-300 ng/mL in men; n = 663), and high (>200 ng/mL in women and >300 ng/mL in men; n = 247) ferritin levels. Multivariable Cox proportional hazards models were used to evaluate the relationship between ferritin and incident HF. After 21 ± 4.6 years of follow-up, HF occurred in 144 (13.5%) participants. When compared with participants with normal ferritin levels, participants with low ferritin levels had a higher risk of HF [hazard ratio (HR) = 2.24, 95% confidence interval (CI) 1.15-4.35; P = 0.02] as did those with high ferritin levels (HR = 1.81, 95% CI 1.01-3.25; P = 0.04), after adjusting for potential confounders. Notably, low ferritin levels remained associated with incident HF even after excluding subjects with anaemia (HR = 2.28, 95% CI 1.11-4.68; P = 0.03). CONCLUSION Derangements in iron metabolism, either low or high ferritin serum levels, were associated with higher risk of incident HF in a general population, even without concurrent anaemia. These findings suggest that iron imbalance might play a role in the development of HF.
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Affiliation(s)
- Odilson M Silvestre
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Alexandra Gonçalves
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,University of Porto Medical School, Porto, Portugal
| | - Wilson Nadruz
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,University of Campinas, Campinas, Brazil
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | | | | | | | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Centre Göttingen (UMG), Göttingen, Germany
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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24
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Mullan J, Weston KM, Bonney A, Burns P, Mullan J, Rudd R. Consumer knowledge about over-the-counter NSAIDs: they don't know what they don't know. Aust N Z J Public Health 2016; 41:210-214. [PMID: 27774735 DOI: 10.1111/1753-6405.12589] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 05/01/2016] [Accepted: 06/01/2016] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To investigate consumers' knowledge about commonly purchased over-the-counter (OTC) products containing ibuprofen. METHODS Customers buying two popular OTC ibuprofen-containing products (Nurofen™ or Nurofen Plus™ ) were asked to complete a short survey assessing their knowledge about the products. RESULTS The survey was completed by 262 respondents, most of whom were older than 50 years of age; female; well-educated; with adequate functional health literacy. The majority correctly identified ibuprofen as an active ingredient and knew the correct intervals between doses. However, almost a third couldn't correctly identify the maximum daily dose and were unaware of some contraindications. Furthermore, fewer than half recognised potential side effects. Those who hadn't completed high school were significantly less likely to seek medical advice (when required) and significantly less likely to know when it was safe to take these products. CONCLUSIONS The gaps in consumer knowledge, especially about the maximum daily dose, contraindications and potential side effects may be placing consumers at risk of experiencing ibuprofen-related adverse events. Implications for public health: Improving consumer knowledge to address these gaps in their understanding about the safe use of popular OTC ibuprofen-containing products is an important public health concern.
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Affiliation(s)
- Judy Mullan
- School of Medicine, University of Wollongong, New South Wales
| | | | - Andrew Bonney
- School of Medicine, University of Wollongong, New South Wales
| | - Pippa Burns
- School of Medicine, University of Wollongong, New South Wales
| | | | - Rima Rudd
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, US
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016; 37:2129-2200. [PMID: 27206819 DOI: 10.1093/eurheartj/ehw128] [Citation(s) in RCA: 8980] [Impact Index Per Article: 1122.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail 2016; 18:891-975. [DOI: 10.1002/ejhf.592] [Citation(s) in RCA: 4631] [Impact Index Per Article: 578.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Schmidt M, Lamberts M, Olsen AMS, Fosbøll E, Niessner A, Tamargo J, Rosano G, Agewall S, Kaski JC, Kjeldsen K, Lewis BS, Torp-Pedersen C. Cardiovascular safety of non-aspirin non-steroidal anti-inflammatory drugs: review and position paper by the working group for Cardiovascular Pharmacotherapy of the European Society of Cardiology. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2016; 2:108-18. [DOI: 10.1093/ehjcvp/pvv054] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 09/07/2015] [Indexed: 01/09/2023]
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Schmidt M, Lamberts M, Olsen AMS, Fosbøll E, Niessner A, Tamargo J, Rosano G, Agewall S, Kaski JC, Kjeldsen K, Lewis BS, Torp-Pedersen C. Cardiovascular safety of non-aspirin non-steroidal anti-inflammatory drugs: review and position paper by the working group for Cardiovascular Pharmacotherapy of the European Society of Cardiology. Eur Heart J 2016; 37:1015-23. [DOI: 10.1093/eurheartj/ehv505] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 09/07/2015] [Indexed: 12/30/2022] Open
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Comparing Nonrandomized Observational Studies With Randomized Controlled Trials in Cervical Disc Arthroplasty: A Meta-analysis. Spine (Phila Pa 1976) 2016; 41:419-28. [PMID: 26679870 DOI: 10.1097/brs.0000000000001377] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To compare the treatment effects of observational studies versus randomized controlled trials (RCTs) in cervical disc arthroplasty. SUMMARY OF BACKGROUND DATA RCTs can be logistically challenging and sometimes insufficiently generalizable; well-designed observational studies have been suggested as an alternative. We hypothesized that treatment effects of observational studies in cervical disc arthroplasty are similar to those of RCTs. METHODS We searched electronic database from 2000 to 2014. The Neck Disability Index (NDI) was the primary outcome from which the standardized pre-and-post mean difference (Hedges's g) was determined. Meta-analysis was performed to compare Hedges's g from observational studies to that of RCTs. Potential moderator variables including study quality, age, gender, industry sponsorship, location by continent, and disc types were also collected and analyzed. Observational studies were further stratified into prospective and retrospective, and they were compared to each other as well as to RCTs. RESULTS We identified nine RCTs, 28 observational studies, and one hybrid study for meta-analysis. NDI Hedges's g was 2.15 for RCTs and 2.03 for observational studies, which was not significant (P = 0.416). No significant difference was found in secondary outcomes. However, after further stratification, prospective observational studies had less treatment effect in Visual Analog Scale neck compared with that of RCTs (1.60 vs. 2.11, P = 0.006). RCTs recruited younger patients (44.1 vs. 45.6, P = 0.008) with worse NDI at baseline (54.30 vs. 46.92, P < 0.001). Patients treated with ProDisc-C showed less standardized improvement on the NDI compared with the patients treated with Prestige (1.41 vs. 2.48, P = 0.026). CONCLUSION Prospective observational studies that utilize the same features of RCTs such as inclusion and exclusion criteria validated clinical outcomes, and statistical methods can provide valuable information about the treatment effects on a generalizable population. LEVEL OF EVIDENCE 4.
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Clinical guidelines «Rational use of nonsteroidal anti-inflammatory drugs (NSAIDs) in clinical practice». Part I. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:70-82. [DOI: 10.17116/jnevro20151154170-82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Caughey GE, Kalisch Ellett LM, Wong TY. Development of evidence-based Australian medication-related indicators of potentially preventable hospitalisations: a modified RAND appropriateness method. BMJ Open 2014; 4:e004625. [PMID: 24776711 PMCID: PMC4010844 DOI: 10.1136/bmjopen-2013-004625] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/17/2014] [Accepted: 04/01/2014] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Indicators of potentially preventable hospitalisations have been adopted internationally as a measure of health system performance; however, few assess appropriate processes of care around medication use, that if followed may prevent hospitalisation. The aim of this study was to develop and validate evidence-based medication-related indicators of potentially preventable hospitalisations. SETTING Australian primary healthcare. PARTICIPANTS Medical specialists, general practitioners and pharmacists. A modified RAND appropriateness method was used for the development of medication-related indicators of potentially preventable hospitalisations, which included a literature review, assessment of the strength of the supporting evidence base, an initial face and content validity by an expert panel, followed by an independent assessment of indicators by an expert clinical panel across various disciplines, using an online survey. PRIMARY OUTCOME MEASURE Analysis of ratings was performed on the four key elements of preventability; the medication-related problem must be recognisable, the adverse outcomes foreseeable and the causes and outcomes identifiable and controllable. RESULTS A total of 48 potential indicators across all major disease groupings were developed based on level III evidence or greater, that were independently assessed by 78 expert clinicians (22.1% response rate). The expert panel considered 29 of these (60.4%) sufficiently valid. Of these, 21 (72.4%) were based on level I evidence. CONCLUSIONS This study provides a set of face and content validated indicators of medication-related potentially preventable hospitalisations, linking suboptimal processes of care and medication use with subsequent hospitalisation. Further analysis is required to establish operational validity in a population-based sample, using an administrative health database. Implementation of these indicators within routine monitoring of healthcare systems will highlight those conditions where hospitalisations could potentially be avoided through improved medication management.
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Affiliation(s)
- Gillian E Caughey
- Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
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Golder S, Loke YK, Bland M. Comparison of pooled risk estimates for adverse effects from different observational study designs: methodological overview. PLoS One 2013; 8:e71813. [PMID: 23977151 PMCID: PMC3748094 DOI: 10.1371/journal.pone.0071813] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 07/03/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A diverse range of study designs (e.g. case-control or cohort) are used in the evaluation of adverse effects. We aimed to ascertain whether the risk estimates from meta-analyses of case-control studies differ from that of other study designs. METHODS Searches were carried out in 10 databases in addition to reference checking, contacting experts, and handsearching key journals and conference proceedings. Studies were included where a pooled relative measure of an adverse effect (odds ratio or risk ratio) from case-control studies could be directly compared with the pooled estimate for the same adverse effect arising from other types of observational studies. RESULTS We included 82 meta-analyses. Pooled estimates of harm from the different study designs had 95% confidence intervals that overlapped in 78/82 instances (95%). Of the 23 cases of discrepant findings (significant harm identified in meta-analysis of one type of study design, but not with the other study design), 16 (70%) stemmed from significantly elevated pooled estimates from case-control studies. There was associated evidence of funnel plot asymmetry consistent with higher risk estimates from case-control studies. On average, cohort or cross-sectional studies yielded pooled odds ratios 0.94 (95% CI 0.88-1.00) times lower than that from case-control studies. INTERPRETATION Empirical evidence from this overview indicates that meta-analysis of case-control studies tend to give slightly higher estimates of harm as compared to meta-analyses of other observational studies. However it is impossible to rule out potential confounding from differences in drug dose, duration and populations when comparing between study designs.
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Affiliation(s)
- Su Golder
- Centre for Reviews and Dissemination (CRD), University of York, York, United Kingdom
| | - Yoon K. Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Martin Bland
- Department of Health Sciences, University of York, York, United Kingdom
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Patrício JPH, Barbosa JPP, Ramos RMM, Antunes NFP, de Melo PCS. Relative cardiovascular and gastrointestinal safety of non-selective non-steroidal anti-inflammatory drugs versus cyclo-oxygenase-2 inhibitors: implications for clinical practice. Clin Drug Investig 2013; 33:167-83. [PMID: 23338974 DOI: 10.1007/s40261-013-0052-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used in clinical practice, and are considered a first-line option for pain management. However, non-selective NSAIDs (nsNSAIDs) and new generation NSAIDs named cyclo-oxygenase-2 inhibitors (coxibs) are very different from one another and their cardiovascular and gastrointestinal safety profiles may influence prescribing. This article resulted from a search of MEDLINE/Pubmed, Cochrane Library, Bandolier, Medscape and Trip database, up to June 2011. Key words included non-steroidal anti-inflammatory, coxib and safety, with the purpose of reviewing the gastrointestinal and cardiovascular safety issues of NSAIDS and the main aspects that differentiate both classes. Selective coxibs are associated with a more favourable gastrointestinal safety profile than nsNSAIDs. In terms of the risk of cardiovascular events, there seems to be a class effect for all NSAIDs with the possible exception of naproxen. The proper usage guidelines for NSAIDs detail the importance of risk factors for each patient in addition to the differences between classes. Patients with high cardiovascular or gastrointestinal risk should avoid using NSAIDs. These medications should be used at the minimum effective dose and for the shortest time possible in all patients.
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Küster M, Renner B, Oppel P, Niederweis U, Brune K. Consumption of analgesics before a marathon and the incidence of cardiovascular, gastrointestinal and renal problems: a cohort study. BMJ Open 2013; 3:bmjopen-2012-002090. [PMID: 23604350 PMCID: PMC3641448 DOI: 10.1136/bmjopen-2012-002090] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To prevent pain inhibiting their performance, many athletes ingest over-the-counter (OTC) analgesics before competing. We aimed at defining the use of analgesics and the relation between OTC analgesic use/dose and adverse events (AEs) during and after the race, a relation that has not been investigated to date. DESIGN Prospective (non-interventional) cohort study, using an online questionnaire. SETTING The Bonn marathon 2010. PARTICIPANTS 3913 of 7048 participants in the Bonn marathon 2010 returned their questionnaires. PRIMARY AND SECONDARY OUTCOMES Intensity of analgesic consumption before sports; incidence of AEs in the cohort of analgesic users as compared to non-users. RESULTS There was no significant difference between the premature race withdrawal rate in the analgesics cohort and the cohort who did not take analgesics ('controls'). However, race withdrawal because of gastrointestinal AEs was significantly more frequent in the analgesics cohort than in the control. Conversely, withdrawal because of muscle cramps was rare, but it was significantly more frequent in controls. The analgesics cohort had an almost 5 times higher incidence of AEs (overall risk difference of 13%). This incidence increased significantly with increasing analgesic dose. Nine respondents reported temporary hospital admittance: three for temporary kidney failure (post-ibuprofen ingestion), four with bleeds (post-aspirin ingestion) and two cardiac infarctions (post-aspirin ingestion). None of the control reported hospital admittance. CONCLUSIONS The use of analgesics before participating in endurance sports may cause many potentially serious, unwanted AEs that increase with increasing analgesic dose. Analgesic use before endurance sports appears to pose an unrecognised medical problem as yet. If verifiable in other endurance sports, it requires the attention of physicians and regulatory authorities.
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Affiliation(s)
- Michael Küster
- Pain Management Center DGS, Bonn, Bad-Godesberg, Germany
| | - Bertold Renner
- Department of Experimental and Clinical Pharmacology and Toxicology, FAU Erlangen-Nuremberg, Erlangen, Germany
| | - Pascal Oppel
- Department of Experimental and Clinical Pharmacology and Toxicology, FAU Erlangen-Nuremberg, Erlangen, Germany
| | - Ursula Niederweis
- Department of Experimental and Clinical Pharmacology and Toxicology, FAU Erlangen-Nuremberg, Erlangen, Germany
| | - Kay Brune
- Department of Experimental and Clinical Pharmacology and Toxicology, FAU Erlangen-Nuremberg, Erlangen, Germany
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Zeidan AZ, Al Sayed B, Bargaoui N, Djebbar M, Djennane M, Donald R, El Deeb K, Joudeh RA, Nabhan A, Schug SA. A review of the efficacy, safety, and cost-effectiveness of COX-2 inhibitors for Africa and the Middle East region. Pain Pract 2012; 13:316-31. [PMID: 22931375 DOI: 10.1111/j.1533-2500.2012.00591.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite an increasingly sophisticated understanding of pain mechanisms, acute and chronic pain remain undertreated throughout the world. This situation reflects the large gap that exists between evidence and practice in pain management and is typified by inappropriate use of nonsteroidal anti-inflammatory drugs (NSAIDs). The scientific evidence around these drugs continues to expand at a high rate, yet physicians are often unaware of best practice. To address this gap among physicians in Africa and the Middle East, an Expert Panel meeting was convened with representatives from the region. The principal objective of the meeting was to review the latest guidelines on the management of acute and chronic pain and to review the efficacy, safety, and cost-effectiveness of cyclooxygenase-2 (COX-2) inhibitors in these settings. The main outcome of this review process was a number of consensus statements concerning the definitions of acute and chronic pain, and the efficacy, safety and cost-effectiveness of traditional nonselective NSAIDs (nsNSAIDs) and selective COX-2 inhibitors (coxibs). The panel agreed that nsNSAIDs and coxibs are effective analgesics with similar efficacy for acute pain; for chronic musculoskeletal pain, NSAIDs are significantly more effective than either placebo or paracetamol. Coxibs offer important safety advantages over nsNSAIDs, including gastrointestinal safety and preservation of platelet function; notably, the cardiovascular safety of coxibs has been the subject of much recent debate. Furthermore, the panel agreed there is substantial evidence to indicate that cost savings can be achieved by using celecoxib in patients at moderate to high risk of gastrointestinal adverse events, even in countries with moderate healthcare expenditures.
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Affiliation(s)
- Anwar Z Zeidan
- Faculty of Medicine, Alexandria University, Alexandria, Egypt.
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Ronco C, Cicoira M, McCullough PA. Cardiorenal syndrome type 1: pathophysiological crosstalk leading to combined heart and kidney dysfunction in the setting of acutely decompensated heart failure. J Am Coll Cardiol 2012; 60:1031-42. [PMID: 22840531 DOI: 10.1016/j.jacc.2012.01.077] [Citation(s) in RCA: 206] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 01/13/2012] [Indexed: 01/11/2023]
Abstract
Cardiorenal syndrome (CRS) type 1 is characterized as the development of acute kidney injury (AKI) and dysfunction in the patient with acute cardiac illness, most commonly acute decompensated heart failure (ADHF). There is evidence in the literature supporting multiple pathophysiological mechanisms operating simultaneously and sequentially to result in the clinical syndrome characterized by a rise in serum creatinine, oliguria, diuretic resistance, and in many cases, worsening of ADHF symptoms. The milieu of chronic kidney disease has associated factors including obesity, cachexia, hypertension, diabetes, proteinuria, uremic solute retention, anemia, and repeated subclinical AKI events all work to escalate individual risk of CRS in the setting of ADHF. All of these conditions have been linked to cardiac and renal fibrosis. In the hospitalized patient, hemodynamic changes leading to venous renal congestion, neurohormonal activation, hypothalamic-pituitary stress reaction, inflammation and immune cell signaling, systemic endotoxemic exposure from the gut, superimposed infection, and iatrogenesis all contribute to CRS type 1. The final common pathway of bidirectional organ injury appears to be cellular, tissue, and systemic oxidative stress that exacerbate organ function. This review explores in detail the pathophysiological pathways that put a patient at risk and then effectuate the vicious cycle now recognized as CRS type 1.
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Affiliation(s)
- Claudio Ronco
- Department of Nephrology, Dialysis, and Transplantation, St. Bortolo Hospital, Vicenza, Italy.
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Hamburger M, Baraf HSB, Adamson TC, Basile J, Bass L, Cole B, Doghramji PP, Guadagnoli GA, Hamburger F, Harford R, Lieberman JA, Mandel DR, Mandelbrot DA, McClain BP, Mizuno E, Morton AH, Mount DB, Pope RS, Rosenthal KG, Setoodeh K, Skosey JL, Edwards NL. 2011 recommendations for the diagnosis and management of gout and hyperuricemia. PHYSICIAN SPORTSMED 2011; 39:98-123. [PMID: 22293773 DOI: 10.3810/psm.2011.11.1946] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Gout is a major health problem in the United States; it affects 8.3 million people, which is approximately 4% of the adult population. Gout is most often diagnosed and managed in primary care practices; thus, primary care physicians have a significant opportunity to improve patient outcomes. Following publication of the 2006 European League Against Rheumatism (EULAR) gout guidelines, significant new evidence has accumulated, and new treatments for patients with gout have become available. It is the objective of these 2011 recommendations to update the 2006 EULAR guidelines, paying special attention to the needs of primary care physicians. The revised 2011 recommendations are based on the Grading of Recommendations Assessment, Development, and Evaluation approach as an evidence-based strategy for rating quality of evidence and grading the strength of recommendation formulated for use in clinical practice. A total of 26 key recommendations, 10 for diagnosis and 16 for management, of patients with gout were evaluated, resulting in important updates for patient care. The presence of monosodium urate crystals and/or tophus and response to colchicine have the highest clinical diagnostic value. The key aspect of effective management of an acute gout attack is initiation of treatment within hours of symptom onset. Low-dose colchicine is better tolerated and is as effective as a high dose. When urate-lowering therapy (ULT) is indicated, the xanthine oxidase inhibitors allopurinol and febuxostat are the options of choice. Febuxostat can be prescribed at unchanged doses for patients with mild-to-moderate renal or hepatic impairment. The target of ULT should be a serum uric acid level that is ≤ 6 mg/dL. For patients with refractory and tophaceous gout, intravenous pegloticase is a new treatment option. This article is a summary of the 2011 clinical guidelines published in Postgraduate Medicine. This article provides a streamlined, accessible overview intended for quick review by primary care physicians, with the full guidelines being a resource for those seeking additional background information and expanded discussion.
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Stefansdottir G, De Bruin ML, Knol MJ, Grobbee DE, Leufkens HG. Randomized Controlled Trials of COX-2 Inhibitors. Drug Saf 2011; 34:783-92. [DOI: 10.2165/11590470-000000000-00000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Meta-analyses of adverse effects data derived from randomised controlled trials as compared to observational studies: methodological overview. PLoS Med 2011; 8:e1001026. [PMID: 21559325 PMCID: PMC3086872 DOI: 10.1371/journal.pmed.1001026] [Citation(s) in RCA: 201] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 03/15/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There is considerable debate as to the relative merits of using randomised controlled trial (RCT) data as opposed to observational data in systematic reviews of adverse effects. This meta-analysis of meta-analyses aimed to assess the level of agreement or disagreement in the estimates of harm derived from meta-analysis of RCTs as compared to meta-analysis of observational studies. METHODS AND FINDINGS Searches were carried out in ten databases in addition to reference checking, contacting experts, citation searches, and hand-searching key journals, conference proceedings, and Web sites. Studies were included where a pooled relative measure of an adverse effect (odds ratio or risk ratio) from RCTs could be directly compared, using the ratio of odds ratios, with the pooled estimate for the same adverse effect arising from observational studies. Nineteen studies, yielding 58 meta-analyses, were identified for inclusion. The pooled ratio of odds ratios of RCTs compared to observational studies was estimated to be 1.03 (95% confidence interval 0.93-1.15). There was less discrepancy with larger studies. The symmetric funnel plot suggests that there is no consistent difference between risk estimates from meta-analysis of RCT data and those from meta-analysis of observational studies. In almost all instances, the estimates of harm from meta-analyses of the different study designs had 95% confidence intervals that overlapped (54/58, 93%). In terms of statistical significance, in nearly two-thirds (37/58, 64%), the results agreed (both studies showing a significant increase or significant decrease or both showing no significant difference). In only one meta-analysis about one adverse effect was there opposing statistical significance. CONCLUSIONS Empirical evidence from this overview indicates that there is no difference on average in the risk estimate of adverse effects of an intervention derived from meta-analyses of RCTs and meta-analyses of observational studies. This suggests that systematic reviews of adverse effects should not be restricted to specific study types. Please see later in the article for the Editors' Summary.
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Mangoni AA, Woodman RJ, Gaganis P, Gilbert AL, Knights KM. Use of non-steroidal anti-inflammatory drugs and risk of incident myocardial infarction and heart failure, and all-cause mortality in the Australian veteran community. Br J Clin Pharmacol 2010; 69:689-700. [PMID: 20565461 DOI: 10.1111/j.1365-2125.2010.03627.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS We studied the association between either non-selective NSAIDs (ns-NSAIDs), selective COX-2 inhibitors, or any NSAID and risk of incident myocardial infarction (MI) and heart failure (HF), and all-cause mortality in elderly subjects. METHODS We conducted a retrospective nested case-control study on Australian veterans using nationwide hospital admission and pharmacy dispensing data. We estimated adjusted odds ratios (OR) with 95% confidence intervals (CI) for the risk of events for three different measures of prescription supply exposure over the last 2 years: (i) supplied at least once, (ii) supply frequency: supplied more than twice within the last 30 days, once or twice within the last 30 days, and once or more 30 days to 2 years and (iii) total supplies. RESULTS We identified 83 623 cases and 1 662 099 matched controls (1:20) contributing 3 862 931 persons-years of observation. NSAID use at least once within the last 2 years did not significantly affect the risk of MI (OR 1.00, 95% CI 0.96, 1.04) but was associated with a mildly reduced risk of HF (OR 0.95, 95% CI 0.92, 0.98). There was a reduced all-cause mortality with at least one supply of either ns-NSAIDs (OR 0.94, 95% CI 0.90, 0.97), selective COX-2 inhibitors (OR 0.90, 95% CI 0.88, 0.93), or any NSAID (OR 0.87, 95% CI 0.85, 0.90). Risk of death was also inversely associated with the number of prescription supplies. CONCLUSIONS NSAID use is not associated with an increased risk of incident MI and HF but is associated with a reduction in all-cause mortality in Australian veterans.
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Affiliation(s)
- Arduino A Mangoni
- Department of Clinical Pharmacology, School of Medicine, Flinders University, Australia.
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Abstract
Individuals with osteoarthritis face an increased risk of cardiovascular (CV) disease compared with age-matched control subjects. Both conditions share some common risk factors (eg, age, obesity, and hypertension) and the consequences or treatment of osteoarthritis may increase CV risk by impairing physical activity and exacerbating CV risk factors. Nonsteroidal anti-inflammatory drugs may have prothrombotic and/or hypertensive effects and a negative impact on renal function, all of which contribute to the increased risk of CV disease associated with these agents. The magnitude of these effects differs between agents and is, in part, determined by the relative balance of cyclo-oxygenase-1 or cyclo-oxygenase-2 inhibition. To minimize risk of CV disease in patients with osteoarthritis taking nonsteroidal anti-inflammatory drugs, physicians need to 1) monitor blood pressure and the new appearance or exacerbation of edema; 2) encourage lifestyle changes/nonpharmacologic treatments for pain/risk factor management; 3) choose the lowest effective dose of appropriate drug therapy to achieve adequate pain relief while minimizing CV risk; 4) change nonsteroidal anti-inflammatory drugs as needed to one with lower propensity to aggravate CV risk; and 5) modulate antihypertensive therapy and diuretic management as needed to maintain target blood pressure and weight.
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Martin MWS, Stafford Johnson MJ, Strehlau G, King JN. Canine dilated cardiomyopathy: a retrospective study of prognostic findings in 367 clinical cases. J Small Anim Pract 2010; 51:428-36. [DOI: 10.1111/j.1748-5827.2010.00966.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Langley PC, Patkar AD, Boswell KA, Benson CJ, Schein JR. Adverse event profile of tramadol in recent clinical studies of chronic osteoarthritis pain. Curr Med Res Opin 2010; 26:239-51. [PMID: 19929615 DOI: 10.1185/03007990903426787] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To review the safety profile of tramadol hydrochloride (tramadol) in the treatment of chronic osteoarthritis pain, with specific reference to the incidence of adverse events (AEs) reported in large clinical trials. METHODS An extensive review of published clinical trials with tramadol was conducted, using literature searches in MEDLINE and EMBASE (since 1997) and the key search terms: tramadol, immediate-release (IR), extended-release (ER), sustained-release (SR), chronic pain, and osteoarthritis. Studies were included based on appropriate study design, appropriately reported safety data, and chronic osteoarthritis as a pain condition. Secondary analyses of previously published pain studies were excluded. RESULTS Fifteen studies met the inclusion criteria. The most common AEs reported across all tramadol formulations were nausea, dizziness, constipation, vomiting, somnolence, and headache. Most AEs were mild to moderate in severity and occurred more commonly during initial treatment than during maintenance treatment. Differences in the rates of selected gastrointestinal and central nervous system AEs were seen between long-acting and immediate-release tramadol formulations, both within individual studies and across all studies. AEs appeared to be dose-dependent in fixed-dose studies. CONCLUSIONS This review provides a robust base for descriptive assessment of AEs associated with long-acting tramadol formulations. Although the actions of different tramadol formulations are biologically similar, differences in pharmacokinetics, drug-release patterns, and availability may influence the incidence of AEs associated with tramadol. Because of the limitations of a qualitative safety analysis across studies with different populations and study designs, any observed differences should be interpreted with caution, but these differences may help educate healthcare providers about tramadol treatment in patients with chronic osteoarthritis pain and help them select the optimal dose for specific patients.
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