Anticonvulsant prescription patterns in patients covered by the Colombian Health System

Shift from older- to newer-generation antiseizure medications in people with acute ischemic stroke in Australia: A population-based study

OBJECTIVE

To investigate the trends in antiseizure medications (ASMs) use following ischemic stroke and to examine factors associated with use of newer- and older-generation ASMs.

METHODS

A retrospective cohort study was conducted using state-wide linked health datasets. Patients who were hospitalized with a first-ever ischemic stroke between 2013 and 2017 and were dispensed ASM within 12 months from discharge were included. Logistic regression was used to examine the predictors of receiving newer-generation ASMs. Generalized linear modeling was used to identify factors associated with ASM use after ischemic stroke.

RESULTS

Of 19 601 people hospitalized with a first-ever ischemic stroke, 989 were dispensed an ASM within 12 months from discharge. The most prevalent first ASMs were levetiracetam (38.0%), valproate (25.8%), and carbamazepine (10.3%). Most people were dispensed ASM monotherapy (86.9%). There was a shift toward the use of newer-generation ASMs between 2013 and 2017 (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.92-4.16). Metropolitan residents were more likely to be dispensed newer-generation ASMs as a first-line treatment (OR 1.79, 95% CI 1.31-2.45). People over 85 years (OR 0.38, 95% CI 0.23-0.64), with dementia (OR 0.35, 95% CI 0.19-0.63) and psychotic comorbidities (OR 0.29, 95% CI 0.09-0.96) were less likely to be dispensed newer-generation ASMs. Older age (coefficient [β] 0.23, P = 0.030), history of beta blocker use (β 0.17, P = 0.029), multiple ASMs (β 0.78, P < 0.001), and newer-generation ASM (β 0.23, P = 0.001) were associated with higher defined daily dose (DDD) of ASM whereas female sex and being married were associated with lower DDD.

SIGNIFICANCE

There has been a shift toward newer-generation ASMs for poststroke seizures and epilepsy. Concerningly, vulnerable patient groups were more likely to be dispensed older-generation ASMs. This may lead to unnecessary exposure to adverse events and drug-drug interactions. Further research is needed to evaluate comparative effectiveness and safety of newer- and older-generation ASMs in poststroke populations.

Use of antiseizure medications and safety of branded versus generic formulations: A comparative study on Tuscan administrative databases

PURPOSE

To assess patterns of use of antiseizure medications (ASMs) and to compare the safety of generic versus branded formulations in terms of admission to hospital or to emergency department (ED).

METHODS

We conducted a drug utilization study with a propensity score-matched design using the administrative databases of the Italian Tuscany region. New users of ASMs during 2015 with no history of neoplasia were considered and their first prescription was classified as: available only as branded (only-B-ASM); branded with generic available (B-ASM); and generic (G-ASM). Patients with G-ASM first prescription were matched with four patients with B-ASM prescription. Participants were followed up for one year or until the date of death or diagnosis of neoplasia. Cox regression models were fitted to estimate the risk of admission to hospital or ED.

RESULTS

We identified 36,601 ASM new-users, including 2094 (6.4%) with only-B-ASM as first prescription, 24,588 (74.9%) with B-ASM, and 5788 (17.6%) with G-ASM. We found no differences in the risk of admission to hospital or ED (Hazard Ratio (HR), 0.92; 95% Confidence Interval (CI), 0.85-1.02) among users of generic ASMs compared to those using branded ASMs.

CONCLUSIONS

In our study population, generic ASMs were used less than branded ones. The similarity in the safety of branded and generic formulations suggests that generic ASMs could be the preferred formulation in current clinical practice resulting in a substantial decrease in the cost of treatment.

Availability of secondary healthcare data for conducting pharmacoepidemiology studies in Colombia: A systematic review

Real-world evidence (RWE) is emerging as a fundamental component of the post-marketing evaluation of medicinal products. Even though the focus on RWE studies has increased in Colombia, the availability of secondary data sources to perform this type of research is not well documented. Thus, we aimed at identifying and characterizing secondary data sources available in Colombia. We performed a systematic literature review on PubMed, EMBASE, and VHL using a combination of controlled vocabulary and keywords for the concepts of electronic health records, epidemiologic studies and Colombia. A total of 323 publications were included. These comprised 123 identified secondary data sources including pharmacy dispensing databases, government datasets, disease registries, insurance databases, and electronic heath records, among others. These data sources were mostly used for cross-sectional studies focused on disease epidemiology in a specific population. Almost all databases (95%) contained demographic information, followed by pharmacological treatment (44%) and diagnostic tests (39%). Even though the database owner was identifiable in 94%, access information was only available in 44% of the articles. Only a pharmacy-dispensing database, local cancer registries, and government databases included a description regarding the quality of the information available. The diversity of databases identified shows that Colombia has a high potential to continue enhancing its RWE strategy. Greater efforts are required to improve data quality and accessibility. The linkage between databases will expand data pooling and integration to boost the translational potential of RWE.

Validation of the Status epilepticus severity score (STESS) at high-complexity hospitals in Medellín, Colombia

PURPOSE

The Status Epilepticus Severity Score (STESS) is one of the most well-known clinical scoring systems to predict mortality in status epilepticus (SE). The objective of this study was to validate STESS in a Colombian population.

METHOD

We evaluated historical data of adult patients (age ≥16 years) with a clinical or electroencephalographic diagnosis of SE admitted between 2014 and 2017. Prospectively, we included patients admitted from January to June of 2018. The primary outcome was in-hospital mortality. Receiver operating characteristic (ROC)-analysis, determination of best cutoff values, sensitivity, specificity, and positive and negative likelihood ratios were performed.

RESULTS

The sample was 395 patients, with in-hospital mortality of 16.8 %. The area under the ROC curve for STESS was 0.84. A cutoff point of ≥3 produced the highest sensitivity of 84.9 % (95 % CI 73.9 %-92.5 %) and a specificity of 65.7 % (95 % CI 60.2 %-70.8 %), with a positive likelihood ratio of 2.5 and a negative likelihood ratio of 0.2.

CONCLUSIONS

STESS is a useful tool to predict mortality in patients with SE. In Medellin, Colombia, a STESS < 3 allows the identification of the patients who survive reliably. Those patients with a score <3 may have a better prognosis, and treatment with fewer side effects than anaesthetics could be suggested, always remembering the importance of the treating physician's clinical judgement.

Valproic acid induced necrohemorragic pancreatitis: Case report and diagnostic approach in uncommon pancreatitis

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Is convenient to consider a medication induced necrohemorragic pancreatitis in patients without clear causative agent.

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Because progressive increase in AP incidence and the impact on morbidity and mortality is crucial determine an etiologic diagnosis in order to proceed to appropriate therapeutic interventions as for recurrence prevention.

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The valproic acid is a strong AP inducer (class Ia) in its evidence based classification and review of literature on medication induced AP, with the biomolecular evidence of pancreatic injury.

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An adequate initial approach with a complete clinical history and pharmacological background, good physical examination, and pertinent extension of laboratory tests are necessary in order to achieve a proper AP etiology.

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The etiologic diagnosis algorithm for AP proposed could be considered as a diagnostic exclusion tool, and is easy to apply for a timely therapeutic approach in medication induced AP.

Background

Acute pancreatitis (AP) is one of the most frequent gastrointestinal alterations in the United States. Medication induced AP has been undervalued in the surgical environment as etiologic entity of necrohemorragic pancreatitis (NHP). A case of NHP induced by valproic acid (VA) is presented, and an exclusion diagnostic algorithm is proposed.

Case report

A 29-year-old female with past medical history of migraine controlled with VA was admitted to our institute for acute abdominal pain and peritoneal irritation. An exploratory laparotomy was performed, finding pancreatic necrosis and a diagnosis of NHP was determined. The most frequent etiologies for AP were discarded. An exclusion diagnostic algorithm was performed reaching VA as etiologic gent. The treatment consisted on medication withdrawal, oral restriction, parenteral nutrition, hydration, analgesia and peritoneal wash-outs with a positive outcome.

Conclusion

Is convenient to consider a medication induced AP in patients without clear causative agent, such as the VA case presented. An etiological diagnosis algorithm of exclusion is proposed, for an adequate therapeutic approach in medication induced PNH. Algorithm validation is required.

Off-label use of psychotropic drugs beyond officially approved indications in Colombia

Introducción. El uso de psicofármacos por fuera de las indicaciones aprobadas (off-label) es una práctica común, de la cual no se tiene información en Colombia.Objetivo. Describir el uso off-label de psicofármacos en una entidad promotora de salud de Bogotá D.C.Materiales y métodos. Estudio observacional de prescripción-indicación con una muestra aleatoria de pacientes prescritos con psicofármacos entre enero y junio de 2010. Se evaluaron variables sociodemográficas, clínicas, farmacológicas y de concordancia y se realizaron análisis multivariados buscando asociación con prescripciones no aprobadas.Resultados. Los 420 pacientes evaluados tenían una edad promedio de 44.2±18.8 años, con predominio femenino (67.9%). Se encontró prescripción no aprobada en 58.6-59.8% de los casos; el 84.3% de las formulas fueron hechas por medicina general. Los principales psicofármacos en indicaciones como cefalea tensional e insomnio fueron amitriptilina (n=128; 86.7% de uso no aprobado), trazodona (n=93; 88.2%) y fluoxetina (n=66; 36.4%). En el análisis multivariado se halló que ser un adulto joven (OR=1.99; IC95%: 1.06-3.70; p=0.030), ser tratado por medicina general (OR=3.40; IC95%: 1.50-7.67; p=0.003) y ser formulado con amitriptilina (OR=11.38; IC95%: 5.06-25.58; p<0.001) o trazodona (OR=13.08; IC95%: 5.23-32.68; p<0.001) aumentan la probabilidad de recibir una prescripción no aprobada.Conclusiones. En la aseguradora estudiada, los psicofármacos son utilizados en una importante proporción de indicaciones no aprobadas por las autoridades regulatorias, por lo cual es importante fortalecer la educación y el control para el empleo de los medicamentos de manera racional, efectiva y segura.