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Taylor D, Poulou S, Clark I. The cardiovascular safety of tricyclic antidepressants in overdose and in clinical use. Ther Adv Psychopharmacol 2024; 14:20451253241243297. [PMID: 38827015 PMCID: PMC11141239 DOI: 10.1177/20451253241243297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/07/2024] [Indexed: 06/04/2024] Open
Abstract
Tricyclic antidepressants (TCAs) remain widely prescribed for depression and many other conditions. There may be important differences between individual TCA in regard to their overdose toxicity and their cardiac toxicity in clinical use. We conducted a systematic review to compare the toxicity of individual TCA in overdose and the risk of serious adverse cardiac events occurring with therapeutic doses. We used the fatal toxicity index (FTI) and case fatality ratio as markers of fatality in overdose, and hazard ratios or odds ratios for the risk of cardiovascular adverse events during normal clinical use. In all, 30 reports of mortality in overdose and 14 observational studies assessing the risk of cardiovascular adverse events in clinical use were included. FTI values were of the same order of magnitude (101-102) for all TCAs except lofepramine. Desipramine appears to be somewhat more likely than other TCAs to lead to death in overdose. Amitriptyline, clomipramine, dothiepin/dosulepin, doxepin, trimipramine and imipramine showed broadly similar toxicity and were usually reported to be less toxic than desipramine. Data on nortriptyline were contradictory. Lofepramine had the lowest risk of death in overdose. The rank order of overdose toxicity was broadly consistent between different FTI definitions and between markers used. With respect to the risk of cardiovascular events at clinically relevant exposure, amitriptyline, nortriptyline and lofepramine were associated with a greater risk of in-use cardiotoxicity. All measures of overdose toxicity were subject to external influences and confounding. The continued use of TCAs in depression and other conditions should be minimized when considering their undoubted toxicity in overdose and possible toxicity in normal clinical use.
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Affiliation(s)
- David Taylor
- Pharmacy Department, Maudsley Hospital, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, UK
- Institute of Pharmaceutical Sciences, King’s College London, London, UK
| | - Sofia Poulou
- Institute of Pharmaceutical Sciences, King’s College London, London, UK
| | - Ivana Clark
- Institute of Pharmaceutical Sciences, King’s College London, London, UK
- Pharmacy Department, Maudsley Hospital, London, UK
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2
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Liu D, Hong Y, Chen Z, Ma Y, Xia S, Gu S, Zuo H. The Tryptophan Index Is Associated with Risk of Ischemic Stroke: A Community-Based Nested Case-Control Study. Nutrients 2024; 16:1544. [PMID: 38892478 PMCID: PMC11174068 DOI: 10.3390/nu16111544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND The relative availability of the essential amino acid tryptophan in the brain, as indicated by the tryptophan index, which is the ratio of tryptophan to its competing amino acids (CAAs) in circulation, has been related to major depression. However, it remains unknown whether tryptophan availability is involved in the pathogenesis of ischemic stroke. AIMS We aimed to investigate the relationship between the tryptophan index and the risk of ischemic stroke. METHODS We performed a nested case-control study within a community-based cohort in eastern China over the period 2013 to 2018. The analysis included 321 cases of ischemic stroke and 321 controls matched by sex and date of birth. The plasma levels of tryptophan and CAAs, including tyrosine, valine, phenylalanine, leucine, and isoleucine, were measured by ultra-high-performance liquid chromatography-tandem mass spectrometry. Conditional logistic regression analyses were employed to determine incidence rate ratios (IRRs) and their 95% confidence intervals (CIs). RESULTS After adjustment for body mass index, current smoking status, educational attainment, physical activity, family history of stroke, hypertension, diabetes, hyperlipidemia, and estimated glomerular filtration rate, an elevated tryptophan index was significantly associated with a reduced risk of ischemic stroke in a dose-response manner (IRR, 0.76; 95% CI, 0.63-0.93, per standard deviation increment). The plasma tryptophan or CAAs were not separately associated with the risk of ischemic stroke. CONCLUSIONS The tryptophan index was inversely associated with the risk of ischemic stroke. Our novel observations suggest that the availability of the essential amino acid tryptophan in the brain is involved in the pathogenesis of ischemic stroke.
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Affiliation(s)
- Dong Liu
- School of Public Health, Suzhou Medical College of Soochow University, 199 Ren’ai Rd., Suzhou 215123, China;
- School of Public Health, Nantong University, Nantong 226019, China;
| | - Yan Hong
- School of Public Health, Nantong University, Nantong 226019, China;
| | - Zhenting Chen
- Suzhou Medical College of Soochow University, Suzhou 215123, China; (Z.C.); (Y.M.); (S.X.)
| | - Yifan Ma
- Suzhou Medical College of Soochow University, Suzhou 215123, China; (Z.C.); (Y.M.); (S.X.)
| | - Shangyu Xia
- Suzhou Medical College of Soochow University, Suzhou 215123, China; (Z.C.); (Y.M.); (S.X.)
| | - Shujun Gu
- Department of Chronic Disease Control and Prevention, Changshu Center for Disease Control and Prevention, Suzhou 215501, China;
| | - Hui Zuo
- School of Public Health, Suzhou Medical College of Soochow University, 199 Ren’ai Rd., Suzhou 215123, China;
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Major Chronic Non-Communicable Diseases, Suzhou Medical College of Soochow University, Suzhou 215123, China
- MOE Key Laboratory of Geriatric Diseases and Immunology, Suzhou Medical College of Soochow University, Suzhou 215123, China
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Huang HC, Li WC, Tadrous M, Schumock GT, Touchette D, Awadalla S, Lee TA. Evaluating the use of methods to mitigate bias from non-transient medications in the case-crossover design: A systematic review. Pharmacoepidemiol Drug Saf 2023; 32:939-950. [PMID: 37283212 DOI: 10.1002/pds.5649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/30/2023] [Accepted: 06/02/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE The case-crossover design is a self-controlled study design used to compare exposure immediately preceding an event occurrence with exposure in earlier control periods. The design is most suitable for transient exposures in order to avoid biases that can be problematic when using the case-crossover design for non-transient (i.e., chronic) exposures. Our goal was to conduct a systematic review of case-crossover studies and its variants (case-time-control and case-case-time-control) in order to compare design and analysis choices by medication type. METHODS We conducted a systematic search to identify recent case-crossover, case-time-control, and case-case-time-control studies focused on medication exposures. Articles indexed in MEDLINE and EMBASE using these study designs that were published between January 2015 and December 2021 in the English language were identified. Reviews, methodological studies, commentaries, articles without medications as the exposure of interest, and articles with no available full text were excluded. Study characteristics including study design, outcome, risk window, control window, reporting of discordant pairs, and inclusion of sensitivity analyses were summarized overall and by medication type. We further evaluated the implementation of recommended methods to account for biases introduced by non-transient exposures among articles that used the case-crossover design on a non-transient exposure. RESULTS Of the 2036 articles initially identified, 114 articles were included. The case-crossover was the most common study design (88%), followed by the case-time-control (17%), and case-case-time-control (3%). Fifty-three percent of the articles included only transient medications, 35% included only non-transient medications, and 12% included both. Across years, the proportion of case-crossover articles evaluating a non-transient medication ranged from 30% in 2018 to 69% in 2017. We found that 41% of the articles that evaluated a non-transient medication did not apply any of the recommended methods to account for biases and more than half of which were conducted by authors with no previous publication history of case-crossover studies. CONCLUSION Using the case-crossover design to evaluate a non-transient medication remains common in pharmacoepidemiology. Researchers should apply appropriate design and analysis choices when opting to use a case-crossover design with non-transient medication exposures.
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Affiliation(s)
- Hsiao-Ching Huang
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Wen-Chin Li
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Glen T Schumock
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Daniel Touchette
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Saria Awadalla
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, Illinois, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
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Alqdwah-Fattouh R, Rodríguez-Martín S, Barreira-Hernández D, Izquierdo-Esteban L, Gil M, González-Bermejo D, Fernández-Antón E, Rodríguez-Miguel A, García-Lledó A, Bolúmar F, de Abajo FJ. Selective Serotonin Reuptake Inhibitors and Risk of Noncardioembolic Ischemic Stroke: A Nested Case-Control Study. Stroke 2022; 53:1560-1569. [PMID: 35109681 DOI: 10.1161/strokeaha.121.036661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple studies have reported that the use of selective serotonin reuptake inhibitors (SSRIs) is associated with an increased risk of ischemic stroke; however, this finding may be the result of a confounding by indication. We examined the association using different approaches to minimize such potential bias. METHODS A nested case-control study was carried out in a Spanish primary health-care database over the study period 2001 to 2015. Cases were patients sustaining an ischemic stroke with no sign of cardioembolic or unusual cause. For each case, up to 5 matched controls (for exact age, sex, and index date) were randomly selected. Antidepressants were divided in 6 pharmacological subgroups according to their mechanism of action. The current use of SSRIs (use within a 30-day window before index date) was compared with nonuse, past use (beyond 365 days) and current use of other antidepressants through a conditional logistic regression model to obtain adjusted odds ratios and 95% CI. Only initiators of SSRIs and other antidepressants were considered. RESULTS A total of 8296 cases and 37 272 matched controls were included. Of them, 255 (3.07%) were current users of SSRIs among cases and 834 (2.24%) among controls, yielding an adjusted odds ratio of 1.14 (95% CI, 0.97-1.34) as compared with nonusers, 0.94 (95% CI, 0.77-1.13) as compared with past-users and 0.74 (95% CI, 0.58-0.93) as compared with current users of other antidepressants. No relevant differences were found by duration (≤1, >1 year), sex, age (<70, ≥70 years old) and background vascular risk. CONCLUSIONS The use of SSRIs was not associated with an increased risk of noncardioembolic ischemic stroke. On the contrary, as compared with other antidepressants, SSRIs appeared to be protective.
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Affiliation(s)
- Rasha Alqdwah-Fattouh
- Unit of Epidemiology and Public Health. School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain (R.A.-F., F.B.)
| | - Sara Rodríguez-Martín
- Clinical Pharmacology Unit, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.).,Department of Biomedical Sciences (Pharmacology Sector), School of Medicine, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.)
| | - Diana Barreira-Hernández
- Clinical Pharmacology Unit, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.).,Department of Biomedical Sciences (Pharmacology Sector), School of Medicine, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.)
| | - Laura Izquierdo-Esteban
- Stroke Unit, Department of Neurology, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain (L.I.-E.)
| | - Miguel Gil
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain (M.G., D.G.-B.)
| | - Diana González-Bermejo
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain (M.G., D.G.-B.)
| | - Encarnación Fernández-Antón
- Clinical Pharmacology Unit, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.).,Department of Biomedical Sciences (Pharmacology Sector), School of Medicine, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.)
| | - Antonio Rodríguez-Miguel
- Clinical Pharmacology Unit, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.).,Department of Biomedical Sciences (Pharmacology Sector), School of Medicine, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.)
| | - Alberto García-Lledó
- Department of Cardiology, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain (A.G.-L.).,Department of Medicine, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain (A.G.-L.)
| | - Francisco Bolúmar
- Unit of Epidemiology and Public Health. School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain (R.A.-F., F.B.).,Department of Epidemiology and Biostatistics, Graduate School of Public Health, City University of New York (F.B.).,CIBERESP, Spain (F.B.)
| | - Francisco J de Abajo
- Clinical Pharmacology Unit, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.).,Department of Biomedical Sciences (Pharmacology Sector), School of Medicine, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain (S.R.-M., D.B.-H., E.F.-A., A.R.M., F.J.d.A.)
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Chen ACC, Huang KL, Chen HM, Chen PC, Chen VCH, Chiu WC. Antidepressants and the risk of myocardial infarction among patients with diabetes: A population-based cohort study. J Affect Disord 2021; 294:109-114. [PMID: 34274786 DOI: 10.1016/j.jad.2021.06.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate the impact of antidepressants (ATDs) on the risk of myocardial infarction (MI) among patients with diabetes mellitus (DM). METHODS This was a retrospective population-based cohort study that used data obtained from the National Health Insurance Research Database in Taiwan. The study cohort included diabetic patients who were older than 50 years from 1997 to 2010. We then randomly assigned individuals to the matched cohort at a 1:1 ratio according to their demographic data. Both study and matched cohorts were followed up to compare the risk of MI between patients with and without ATD use from 2000 until the end of 2013. Multivariate Cox proportional hazards models were used to evaluate the relationship between ATD treatment and the occurrence of MI. RESULTS After adjustment for confounders, patients with ATD use of more than 180 days had a lower risk of MI than those without ATD use in the matched cohort (adjusted hazard ratio [HR] = 0.68, 95% confidence interval [CI], 0.66-0.71). The adjusted HRs of MI were 0.77 (95% CI, 0.73-0.81) and 0.56 (95% CI, 052.-0.60) in patients with DM and ATD use of 180 > cDDD ≥ 28 and cDDD ≥ 180, respectively. When the duration of ATD treatment was 180 days or longer, MI risk was significantly reduced (after adjustment) for all classes of ATD except bupropion. CONCLUSIONS Most ATDs, but not bupropion, were associated with significantly reduced risk of MI among the DM population.
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Affiliation(s)
| | - Kuan-Lun Huang
- Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nantou, Taiwan
| | - Hong-Ming Chen
- Department of Psychiatry, Chang Gung Medical Foundation, Chiayi Chang Gung Memorial Hospital, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pau-Chung Chen
- Department of Environmental and Occupational Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Department of Public Health, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Vincent Chin-Hung Chen
- Department of Psychiatry, Chang Gung Medical Foundation, Chiayi Chang Gung Memorial Hospital, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Che Chiu
- Department of Psychiatry, Cathay General Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, Taipei, Taiwan.
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Ghazizadeh-Hashemi F, Bagheri S, Ashraf-Ganjouei A, Moradi K, Shahmansouri N, Mehrpooya M, Noorbala AA, Akhondzadeh S. Efficacy and safety of sulforaphane for treatment of mild to moderate depression in patients with history of cardiac interventions: A randomized, double-blind, placebo-controlled clinical trial. Psychiatry Clin Neurosci 2021; 75:250-255. [PMID: 34033171 DOI: 10.1111/pcn.13276] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/30/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
AIM Depression has been recognized as one of the disorders associated with cardiac interventions such as percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). In the present study, we evaluated the efficacy and safety of sulforaphane in treatment of depression induced by cardiac interventions. METHODS After initial screening, 66 patients with previous history of at least one cardiac intervention and current mild to moderate depression were randomly assigned to two parallel groups receiving either sulforaphane (n = 33) or placebo (n = 33) for six successive weeks. Efficacy was assessed using the Hamilton Rating Scale for Depression (HAM-D) at baseline and week 2, 4, and 6. Safety of the treatments was checked during the trial period. RESULTS Sixty participants completed the clinical trial (n = 30 in each group). Baseline demographic and clinical parameters were all similar among groups. Repeated measures analysis indicated that the sulforaphane group exhibited greater improvement in HAM-D scores throughout the trial (P < 0.001). Response to treatment (≥50% reduction in the HAM-D score) rate was higher in the sulforaphane group at trial endpoint (30% vs 6.67%, P = 0.042). Remission (HAM-D score ≤ 7) rate was also higher in the sulforaphane group; however, the difference was not significant (23.33% vs 3.33%, P = 0.052). Finally, no significant difference was observed between the two groups in terms of frequency of side effects. CONCLUSIONS Sulforaphane could safely improve depressive symptoms induced by cardiac interventions. Further clinical trials with larger sample sizes and longer follow-up periods are warranted to confirm our results.
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Affiliation(s)
| | - Sayna Bagheri
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Ashraf-Ganjouei
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamyar Moradi
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nazila Shahmansouri
- Psychosomatic Research Center, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Mehrpooya
- Cardiovascular Ward, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad-Ali Noorbala
- Psychosomatic Research Center, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Alqdwah-Fattouh R, Rodríguez-Martín S, de Abajo FJ, González-Bermejo D, Gil M, García-Lledó A, Bolúmar F. Differential effects of antidepressant subgroups on risk of acute myocardial infarction: A nested case-control study. Br J Clin Pharmacol 2020; 86:2040-2050. [PMID: 32250461 DOI: 10.1111/bcp.14299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 01/20/2023] Open
Abstract
The primary objective of this study was to investigate the association between antidepressants use and the risk of acute myocardial infarction (AMI). METHODS We conducted a nested case-control study using a primary care database over the period 2002-2015. From a cohort of patients aged 40-99 years, we identified incident AMI cases and randomly selected 5 controls per case, matched to cases for exact age, sex and index date. Exposure to antidepressants were categorised as current, recent, past and nonusers. Adjusted odds ratio (AOR) and 95% confidence interval (CI) were computed using conditional logistic regression to assess the association between the current use of different antidepressants subgroups and AMI as compared to nonuse. Dose and duration effects were explored. RESULTS Totals of 24 155 incident AMI cases and 120 775 controls were included. The current use of antidepressants as a group was associated with a reduced risk (AOR = 0.86; 95% CI: 0.81-0.91), but mainly driven by selective serotonin reuptake inhibitors (AOR = 0.86; 95% CI:0.81-0.93). A reduced risk was also observed with trazodone (AOR = 0.76;95% CI: 0.64-0.91), and clomipramine (AOR = 0.62; 95% CI: 0.40-0.96), whereas no significant effect was observed with other antidepressants. A duration-dependent effect was suggested for selective serotonin reuptake inhibitors, trazodone and clomipramine, while there was no clear dose-dependency. CONCLUSION This study suggests that current use of antidepressants interfering selectively with the reuptake of serotonin, and those antagonizing the 5-HT2A receptor, are associated with a decrease in AMI risk and should be the antidepressants of choice in patients at cardiovascular risk.
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Affiliation(s)
- Rasha Alqdwah-Fattouh
- Unit of Epidemiology and Public Health. School of Medicine, University of Alcalá, Madrid, Spain
| | - Sara Rodríguez-Martín
- Clinical Pharmacology Unit, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain.,Department of Biomedical Sciences (Pharmacology Sector), School of Medicine, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Francisco J de Abajo
- Clinical Pharmacology Unit, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain.,Department of Biomedical Sciences (Pharmacology Sector), School of Medicine, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Diana González-Bermejo
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain
| | - Miguel Gil
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Madrid, Spain
| | - Alberto García-Lledó
- Cardiology Department, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain.,Department of Medicine, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - Francisco Bolúmar
- Unit of Epidemiology and Public Health. School of Medicine, University of Alcalá, Madrid, Spain.,Department of Epidemiology and Biostatistics. Graduate School of Public Health, City University of New York, New York, NY, USA.,Ciberesp, Spain
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Douros A, Dell'Aniello S, Dehghan G, Boivin JF, Renoux C. Degree of serotonin reuptake inhibition of antidepressants and ischemic risk: A cohort study. Neurology 2019; 93:e1010-e1020. [PMID: 31391245 DOI: 10.1212/wnl.0000000000008060] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/30/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess whether use of antidepressants with strong inhibition of serotonin reuptake is associated with a decreased incidence of ischemic stroke and myocardial infarction (MI). METHODS We conducted a cohort study using the UK Clinical Practice Research Datalink and considering new users of selective serotonin reuptake inhibitors (SSRIs) or third-generation antidepressants who were ≥18 years of age between 1995 and 2014. Using a nested case-control approach, we matched each case of a first ischemic stroke or MI identified during follow-up with up to 30 controls on age, sex, calendar time, and duration of follow-up. We estimated incidence rate ratios (RRs) and 95% confidence intervals (CIs) of each outcome associated with current use of strong compared with weak inhibitors of serotonin reuptake using conditional logistic regression. RESULTS The cohort included 938,388 incident users of SSRIs (n = 868,755) or third-generation antidepressants (n = 69,633). Mean age at cohort entry was 46 years (64% women). During follow-up, 15,860 cases of ischemic stroke and 8,626 cases of MI were identified and matched to 473,712 and 258,022 controls, respectively. Compared with current use of weak inhibitors of serotonin reuptake, current use of strong inhibitors was associated with a decreased rate of ischemic stroke (RR 0.88, 95% CI 0.80-0.97), but the effect size was smaller in some sensitivity analyses. The rate of MI was similar between strong and weak inhibitors (RR 1.00, 95% CI 0.87-1.15). CONCLUSION Our large population-based study suggests that antidepressants strongly inhibiting serotonin reuptake may be associated with a small decrease in the rate of ischemic stroke.
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Affiliation(s)
- Antonios Douros
- From the Centre for Clinical Epidemiology (A.D., S.D., G.D., J.-F.B., C.R.), Lady Davis Institute, Jewish General Hospital; Department of Epidemiology, Biostatistics, and Occupational Health (A.D., C.R., J.-F.B.) and Department of Neurology and Neurosurgery (C.R.), McGill University, Montreal, Québec, Canada; and Institute of Clinical Pharmacology and Toxicology (A.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Sophie Dell'Aniello
- From the Centre for Clinical Epidemiology (A.D., S.D., G.D., J.-F.B., C.R.), Lady Davis Institute, Jewish General Hospital; Department of Epidemiology, Biostatistics, and Occupational Health (A.D., C.R., J.-F.B.) and Department of Neurology and Neurosurgery (C.R.), McGill University, Montreal, Québec, Canada; and Institute of Clinical Pharmacology and Toxicology (A.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Golsa Dehghan
- From the Centre for Clinical Epidemiology (A.D., S.D., G.D., J.-F.B., C.R.), Lady Davis Institute, Jewish General Hospital; Department of Epidemiology, Biostatistics, and Occupational Health (A.D., C.R., J.-F.B.) and Department of Neurology and Neurosurgery (C.R.), McGill University, Montreal, Québec, Canada; and Institute of Clinical Pharmacology and Toxicology (A.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Jean-François Boivin
- From the Centre for Clinical Epidemiology (A.D., S.D., G.D., J.-F.B., C.R.), Lady Davis Institute, Jewish General Hospital; Department of Epidemiology, Biostatistics, and Occupational Health (A.D., C.R., J.-F.B.) and Department of Neurology and Neurosurgery (C.R.), McGill University, Montreal, Québec, Canada; and Institute of Clinical Pharmacology and Toxicology (A.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Christel Renoux
- From the Centre for Clinical Epidemiology (A.D., S.D., G.D., J.-F.B., C.R.), Lady Davis Institute, Jewish General Hospital; Department of Epidemiology, Biostatistics, and Occupational Health (A.D., C.R., J.-F.B.) and Department of Neurology and Neurosurgery (C.R.), McGill University, Montreal, Québec, Canada; and Institute of Clinical Pharmacology and Toxicology (A.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany.
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Yang BR, Kwon KE, Kim YJ, Choi NK, Kim MS, Jung SY, Shin JY, Ahn YM, Park BJ, Lee J. The association between antidepressant use and deaths from road traffic accidents: a case-crossover study. Soc Psychiatry Psychiatr Epidemiol 2019; 54:485-495. [PMID: 30474691 DOI: 10.1007/s00127-018-1637-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 11/17/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Antidepressants are some of the most commonly used psychiatric medications, but little information is available about the effects of antidepressant treatment on the risk of traffic accidents across classes of antidepressants or associated with each substance individually. To investigate the relationship between exposure to antidepressants and risk of fatality in road traffic accidents. METHODS We used a Korean national road traffic authority database linked with a national health insurance database between January 1, 2010 and December 31, 2014 and applied a case-crossover design. The study subjects were drivers in South Korea who died from traffic accidents and who had prescriptions for antidepressants within 1 year prior to the date of the accident. We compared the status of prescription for antidepressants with the hazard period and four matched control periods using conditional logistic regression, adjusting for other drug use. The trends of antidepressant utilization were described in terms of the number of prescriptions. A case-case-time-control design was applied to drugs with an increasing trend in use and a significant case-crossover odds ratio (OR). RESULTS A total of 1250 antidepressant-using drivers were included, and an increased risk was observed during the 30-day hazard period (adjusted OR 1.30; 95% CI 1.03-1.63). Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) showed significant risks, but tricyclic antidepressants did not. However, the associations of all antidepressants, SSRIs, SNRIs, escitalopram, and duloxetine did not remain significant after adjusting for trends in utilization. Paroxetine and milnacipran were associated with increased risks, with no obvious increase in their utilization, but the possibility of confounding by indication could have affected the results for milnacipran. CONCLUSION Considering the trends of antidepressant prescription and utilization, the use of paroxetine increased the risk of fatal traffic accidents.
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Affiliation(s)
- Bo Ram Yang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyoung-Eun Kwon
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Republic of Korea
| | - Nam-Kyong Choi
- Department of Health Convergence, Ewha Womans University, Seoul, Republic of Korea
| | - Mi-Sook Kim
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Yong Min Ahn
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Institute of Human Behavioral Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Byung-Joo Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joongyub Lee
- School of Medicine, Inha University, Incheon, Republic of Korea.
- Department of Prevention and Management, Inha University Hospital, 27, Inhang-ro, Jung-gu, Incheon, Republic of Korea.
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Manolis TA, Manolis AA, Manolis AS. Cardiovascular Safety of Psychiatric Agents: A Cautionary Tale. Angiology 2018; 70:103-129. [PMID: 29874922 DOI: 10.1177/0003319718780145] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Psychiatric agents are among the most commonly prescribed medications. Despite the advent of newer generation agents, patients receiving them still experience cardiovascular (CV) side effects. However, these agents may have heterogeneous properties, calling for an individualized approach based on efficacy and also on the particular side effect profile of each specific agent. Proarrhythmic effects arising from drug-induced long-QT syndrome and consequent potentially life-threatening polymorphic ventricular arrhythmias in the form of torsade de pointes, the metabolic syndrome contributing to atherosclerosis and acute coronary syndromes, and drug-induced orthostatic hypotension raise major concerns. Of course, it is also crucial that fear of potential CV adverse effects does not deprive psychiatric patients of appropriate drug therapy. Modification of CV risk factors in psychiatric patients together with optimal management of their CV diseases and appropriate selection of psychotropic agents with greater efficacy and least CV toxicity are of paramount importance in mitigating CV risks and enhancing safety. Identifying patients at high risk of CV complications and close monitoring of all patients receiving these agents are crucial steps to prevent and manage such complications. All these issues are herein reviewed, relevant guidelines are discussed, and schemas are depicted that illustrate the interrelated connections among the psychotropic agents and their CV effects.
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Affiliation(s)
| | | | - Antonis S Manolis
- 3 Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
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