Risks of Adverse Events Following Coprescription of Statins and Calcium Channel Blockers: A Nationwide Population-Based Study

Applying machine learning to the pharmacokinetic modeling of cyclosporine in adult renal transplant recipients: a multi-method comparison

Objective: The aim of this study was to identify the important factors affecting cyclosporine (CsA) blood concentration and estimate CsA concentration using seven different machine learning (ML) algorithms. We also assessed the predictability of established ML models and previously built population pharmacokinetic (popPK) model. Finally, the most suitable ML model and popPK model to guide precision dosing were determined.

Methods: In total, 3,407 whole-blood trough and peak concentrations of CsA were obtained from 183 patients who underwent initial renal transplantation. These samples were divided into model-building and evaluation sets. The model-building set was analyzed using seven different ML algorithms. The effects of potential covariates were evaluated using the least absolute shrinkage and selection operator algorithms. A separate evaluation set was used to assess the ability of all models to predict CsA blood concentration. R squared (R2) scores, median prediction error (MDPE), median absolute prediction error (MAPE), and the percentages of PE within 20% (F20) and 30% (F30) were calculated to assess the predictive performance of these models. In addition, previously built popPK model was included for comparison.

Results: Sixteen variables were selected as important covariates. Among ML models, the predictive performance of nonlinear-based ML models was superior to that of linear regression (MDPE: 3.27%, MAPE: 34.21%, F20: 30.63%, F30: 45.03%, R2 score: 0.68). The ML model built with the artificial neural network algorithm was considered the most suitable (MDPE: −0.039%, MAPE: 25.60%, F20: 39.35%, F30: 56.46%, R2 score: 0.75). Its performance was superior to that of the previously built popPK model (MDPE: 5.26%, MAPE: 29.22%, F20: 33.94%, F30: 51.22%, R2 score: 0.68). Furthermore, the application of the most suitable model and the popPK model in clinic showed that most dose regimen recommendations were reasonable.

Conclusion: The performance of these ML models indicate that a nonlinear relationship for covariates may help to improve model predictability. These results might facilitate the application of ML models in clinic, especially for patients with unstable status or during initial dose optimization.

Valacyclovir-associated neurotoxicity among patients on hemodialysis and peritoneal dialysis: A nationwide population-based study

Whether valacyclovir-associated neurotoxicity (VAN) occurs more frequently in patients with end-stage renal disease (ESRD) on dialysis is unknown. This is the first population-based study to examine the risk of VAN associated with ESRD patients on dialysis. Among 2,284,800 patients diagnosed as having herpes zoster from 2002 to 2016, patients with ESRD on dialysis and individuals with normal renal function were enrolled in this study. Following propensity score matching, we compared the risk of altered mental status between valacyclovir users and non-users in the ESRD and normal renal function cohorts over a 30-day follow-up period. In the ESRD cohort, the incidence of altered mental status was 1.68 and 0.52 per 1,000 person-day in valacyclovir users and non-users, respectively, with an adjusted hazard ratio (HR) of 3.22 (95% confidence interval [CI]: 2.04–4.99, P < 0.001). The incidence of altered mental status of valacyclovir users on hemodialysis (HD) and peritoneal dialysis (PD) was higher than that of non-users. The adjusted HR was 3.20 (95% CI: 1.98–5.15, P < 0.001) for those on HD and 3.44 (95% CI: 1.13–10.49, P = 0.030) for those with PD. However, altered mental status was not observed in patients on HD receiving ≤500 mg of valacyclovir three times per week or in those on PD receiving ≤500 mg of valacyclovir per day. The findings demonstrate that adjusting the valacyclovir dosage and monitoring VAN in patients with HD and PD who have herpes zoster is crucial.

Clinical and electrocardiogram presentations of patients with high serum potassium concentrations within emergency settings: a prospective study

BACKGROUND

Elevated potassium level is a common and reversible peri-arrest condition. Diagnosis and management of hyperkalemia in a short time is critical, where electrocardiogram (ECG) alterations might be helpful. We aimed to investigate the role of clinical features and ECGs in early diagnosing and treating hyperkalemia.

METHODS

Prospectively, adult patients who presented to the emergency department (ED) from July 2019 to March 2020 with hyperkalemia (serum potassium ≥5.5mmol/L) were included. History was obtained, and laboratory investigations and ECGs were performed at the presentation and before initiating hyperkalemia therapy. Hyperkalemia severity was divided into mild (5.5-5.9mmol/L), moderate (6.0-6.4mmol/L), and severe (≥6.5mmol/L). A cardiologist and emergency physician blinded to laboratory values, study design, and patients' diagnoses interpreted ECGs and presenting symptoms independently to predict hyperkalemia.

RESULTS

Sixty-seven hyperkalemic patients with a mean (±SD) serum potassium level of 6.5±0.7mmol/L were included in this study. The mean age was 63.9±15.1, and 58.2% were females. Hyperkalemia was mild in 10.4%, moderate in 40.3%, and severe in 49.3%. Almost two thirds of patients (71.6%) had hypertension, 67.2% diabetes, and 64.2% chronic kidney disease. About one-quarter of patients (22.4%) were asymptomatic, while fatigue (46.3%), dyspnea (28.4%), and nausea/vomiting (20.9%) were the most common presenting symptoms. Normal ECGs were observed in 25.4% of patients, while alterations in 74.6%. Atrial fibrillation (13.4%), peaked T wave (11.9%), widened QRS (11.9%), prolonged PR interval (10.5%), and flattening P wave (10.5%) were the most common. Peaked T wave was significantly more common in severe hyperkalemia (87.5%) than in mild and moderate hyperkalemia (12.5%, 0.0%, respectively) (p=0.041). The physicians' sensitivities for predicting hyperkalemia were 35.8% and 28.4%, improved to 51.5% and 42.4%, respectively, when limiting the analyses to severe hyperkalemia. The mean (±SD) time to initial hyperkalemia treatment was 63.8±31.5 min. Potassium levels were positively correlated with PR interval (r=0.283, p=0.038), QRS duration (r=0.361, p=0.003), peaked T wave (r=0.242, p=0.041), and serum levels of creatinine (r=0.347, p=0.004), BUN (r=0.312, p=0.008), and CK (r=0.373, p=0.039).

CONCLUSIONS

The physicians' abilities to predict hyperkalemia based on ECG and symptoms were poor. ECG could not be solely relied on, and serum potassium tests should be conducted for accurate diagnosis.

Association Between DPP-4 Inhibitors and Events of Colorectal and Liver Cancers in Patients With Diabetes Receiving Second-Line Agents: A Nested Case-Control Study

Objective

Plasma dipeptidyl peptidase-4 (DPP4) levels were significantly lower in patients with colorectal and liver cancers, and animal studies also showed DPP4 inhibitors (DPP4is) have procarcinogenic effects in colorectal cancer. Until now, whether DPP4is therapy affects the progression of liver cancer and colorectal cancer in patients with T2DM has not been well investigated. We investigated the association between cumulative defined daily dose (cDDD) of DPP4is exposure and risks of liver and colorectal cancers in patients with type 2 diabetes.

Materials and Methods

We identified 268,520 patients with diabetes receiving DPP4is as second-line agents between March 1, 2009, and December 31, 2013, from Taiwan’s National Health Insurance Research Database, Taiwan Cancer Registry, and National Death Registry of Taiwan. The amount of DPP4is were divided into three groups (low, medium, and high) based on the interquartile range of the cDDD of the DPP4is.

Results

The data showed that the low cDDD of DPP-4is was associated with a reducing risk of colorectal cancer [adjusted odds ratio (OR), 0.49; 95% CI, 0.32–0.75; P=0.001]. However, the high cDDD of DPP-4is was associated with an increasing risk of colorectal cancer (adjusted OR, 1.86; 95% CI, 1.32–2.61; P&lt;0.001). No association between DPP4is use and liver cancer risk was observed.

Conclusions

This nested case study revealed a J-shaped association between the cDDD of DPP-4is and colorectal cancer risk, but not liver cancer risk. Therefore, the effects of long-term DPP4is use on colorectal cancer risk warrant further study.

Pharmacokinetic Drug Interaction Between Amlodipine and Tadalafil: An Open-Label, Randomized, Multiple-Dose Crossover Study in Healthy Male Volunteers

Purpose

The combined administration of tadalafil, a phosphodiesterase-5 inhibitor, and amlodipine, a calcium channel blocker, can be a promising therapeutic option for hypertension patients with erectile dysfunction. This study aimed to examine the pharmacokinetic drug interaction between tadalafil and amlodipine and the tolerability of their combined administration in healthy male subjects.

Subjects and Methods

Healthy volunteers (N = 24) were randomly assigned to one of the six sequences that consisted of three treatments: tadalafil (5 mg) alone, amlodipine (10 mg) alone, and tadalafil plus amlodipine. The study drugs were administered orally for 9 d, and the collected serial blood samples were analyzed up to 72 h after the last dosing. Pharmacokinetic parameters were calculated using non-compartmental analysis.

Results

For tadalafil, geometric mean ratios (GMRs) (90% confidence interval (CI)) of the combined therapy over the monotherapy were 1.57 (1.46–1.68) for AUC_τ,ss and 1.34 (1.24–1.45) for C_max,ss. For amlodipine, the GMRs (90% CI) of AUC_τ,ss and C_max,ss were 0.93 (0.90–0.97) and 0.95 (0.91–0.99), respectively. The severity of all observed adverse events (AEs) related to the study drugs was mild, and the frequency of AEs of the combined administration was not significantly different from the monotherapy.

Conclusion

A substantial pharmacokinetic drug interaction between tadalafil and amlodipine was observed with respect to the concentration of tadalafil when administered concomitantly. However, the dose range of the combined administration of tadalafil and amlodipine in the present study was well tolerated by the subjects.

Optimal Medical Therapy for Chronic Coronary Syndrome: Realities and Prospects

Combination therapy is the standard of treatment for virtually all current non-communicable diseases, primarily chronic coronary heart disease, in modern terminology - "chronic coronary syndrome" (CSS), arterial hypertension, chronic heart failure, diabetes mellitus. The need for a combination of drugs increases even more with comorbidity, which is a typical situation in clinical practice. The recently accumulated material requires a review of the possibility of percutaneous coronary intervention and coronary bypass surgery in prolonging the life of patients with CCS, focusing on providing optimal medical therapy (OMT) for each patient with CCS, based on long-term treatment with antiplatelet agents, statins, angiotensin converting enzyme in-hibitors/angiotensin receptor blockers, beta-blockers. OMT aimed at preventing cardiovascular events and relieving symptoms in patients with CCS requires maximum commitment - a key factor in achieving therapeutic goals. Insufficient adherence of patients to prescribed therapy and its absence are the main barriers to increasing the survival rate of patients with cardiovascular diseases in primary and secondary prevention in the Russian Federation, as evidenced by numerous registers. The desire of the doctor to individualize treatment, which inevitably complicates the use of drugs, pushes patient adherence to treatment into the background. As a result, the patient's lack of commitment to each of the pharmaceuticals destroys the applicability of the OMT concept. A great achievement of the current stage of development of clinical cardiology and the pharmaceutical industry is the ability to offer patients optimal single pill combinations (SPC) in terms of effectiveness, tolerability, drug interactions, and ease of use. The article substantiates the prospects for a successful solution of this key problem by using a new generation of SPC components belonging to different pharmacological groups. The combination of three components (lisinopril, amlodipine and rosuvastatin), each of which has pleiotropic effects, provides a multi-targeted effect with a single dose, with the possibility of individualization of therapy, which is provided by four dosage options within this SPC.

Prescription of statins and pharmacokinetic interactions in Colombian patients

Background: Statins have extensive hepatic metabolism and can have multiple pharmacological interactions. The aim was to identify the main pharmacokinetic interactions between statins and their comedications in a group of patients from Colombia.Research design and methods: A cross-sectional study of pharmacokinetic interactions in patients treated with statins who were identified from a population database. The interactions were documented using the Lexicomp® database.Results: A total of 123,026 patients with statin prescriptions were identified, with a mean age of 68.4 ± 11.5 years; 57.1% were women, and 81.6% received atorvastatin. A total of 19.4% (n = 23.831) of patients presented pharmacological interactions. Some 15,474 (12.6%) had interactions classified as category C, 7.4% (n = 9077) as category D, and 0.5% (n = 660) as category X. 36.8% of the patients with lovastatin prescriptions had some interaction. Age older than 65 years, male sex, residence in capital cities, comorbidities, endocrine pathologies and HIV were associated with an increase in the probability of having contraindicated or risky interactions.Conclusions: Important interactions between statins and other medications were more common in adults over 65 years of age and those with endocrine comorbidities or HIV infection. This knowledge should help when proposing solutions that reduce the risk of adverse reactions.

Toward a broader view of mechanisms of drug cardiotoxicity

Cardiotoxicity, defined as toxicity that affects the heart, is one of the most common adverse drug effects. Numerous drugs have been shown to have the potential to induce lethal arrhythmias by affecting cardiac electrophysiology, which is the focus of current preclinical testing. However, a substantial number of drugs can also affect cardiac function beyond electrophysiology. Within this broader sense of cardiotoxicity, this review discusses the key drug-protein interactions known to be involved in cardiotoxic drug response. We cover adverse effects of anticancer, central nervous system, genitourinary system, gastrointestinal, antihistaminic, anti-inflammatory, and anti-infective agents, illustrating that many share mechanisms of cardiotoxicity, including contractility, mitochondrial function, and cellular signaling.

Lipid-lowering therapy in outpatients of different ages with coronary artery disease

Aim. To conduct a pharmacoepidemiologic analysis of lipid-lowering therapy (LLT) in outpatients of different ages with coronary artery disease (CAD).

Material and methods. A total of 805 medical records of outpatients with CAD were analyzed in this pharmacoepidemiologic, cross-sectional study conducted at primary care facility of Moscow. The total sample of patients was divided into 3 age groups: group 1 — <65 years (n=267; 33,2%), group 2 — 65-74 years (n=305; 37,9%), group 3 — ≥75 years (n=233; 28,9%). Data on LLT (prescription rates, structure, intensity), prevalence of irrational drug combinations, lipid profile were collected. Statistical analysis was performed using SciPy 1.4.1, NumPy 1.18.4 for Python 3.73. Differences were considered significant at p<0,05.

Results. LLT prescription rates were equally high in all ages — 92,9%, 85,9%, and 81,6% in groups 1, 2, and 3 respectively (p>0,05). Dual LLT was prescribed rarely (4,9%, 3,9%, 0,9%, respectively), especially in patients ≥75 years (p<0,05 for groups 1 and 3, p»0,05 for groups 2 and 3). Atorvastatin prevailed in all ages (p>0,05); patients ≥75 received rosuvastatin less often (p<0,05 for groups 1 and 3); simvastatin was more frequently prescribed to patients ≥65 years (p<0,05 for groups 1 and 2, 1 and 3). Prescription rate of high-intensity LLT was higher in group 1 (57,3%) compared with group 2 (40,1%; p<0,05) and group 3 (30,0%; p<0,01). Prevalence of polypharmacy (50,2%, 56,5%, 60,4%) and irrational drug combinations (34,0%, 38,1%, 43,3%) was comparable in all groups (p>0,05), as well as the proportion of patients not achieved target LDL-C <1,8 mmol/l (72,9%, 73,9%, 84,3%; p>0,05).

Conclusion. The study demonstrated no significant influence of patient age on LLT prescription rates, LDL-C control, and prevalence of irrational drug combinations in outpatients with CAD. Rates of dual LLT, structure and intensity of statin therapies differed depending on age groups.

Long-Term Effects of Ketoanalogues on Mortality and Renal Outcomes in Advanced Chronic Kidney Disease Patients Receiving a Low-Protein Diet

The effects of ketoanalogues (KA) supplementation on mortality and progression to dialysis in patients with pre-dialysis stage 5 chronic kidney disease (CKD) receiving a low-protein diet (LPD) remain ambiguous. From Taiwan’s National Health Insurance Research Database during 1996–2011, 165 patients with pre-dialysis CKD on an LPD (0.6 g/kg/day) with KA supplementation were matched with 165 patients with pre-dialysis CKD on an LPD without KA supplementation. Of the 165 patients with advanced CKD receiving KA supplementation, 34 (20.6%) died, and 124 (75.2%) underwent long-term dialysis during the study period. There was no significant difference in mortality between the KA-user group and the KA-nonuser group (adjusted hazard ratio [HR], 1.41; 95% confidence interval [CI], 0.68–2.93; p = 0.355). KA supplementation significantly increased long-term dialysis risk (adjusted HR, 1.41; 95% CI, 1.04–1.90; p = 0.025) and combined outcome risk (defined as long-term dialysis and death; adjusted HR, 1.37; 95% CI, 1.02–1.83; p = 0.034). KA supplementation also increased long-term dialysis risk (adjusted HR, 1.49; 95% CI, 1.00–2.20; p = 0.048) in the subgroup of pre-dialysis patients with diabetes mellitus (DM), but not in those patients without DM. In conclusion, KA supplementation might increase long-term dialysis risk in patients with advanced CKD receiving an LPD, but it did not increase mortality.

From Low-Dose Fixed Combinations for Arterial Hypertension Treatment to Multi-Target Therapy of Cardiovascular Diseases

The article presents the evolutionary development of combination therapy from the creation of a multicomponent tablet for the treatment of arterial hypertension (AH) to modern multi-target fixed combinations as the most effective approach to the fight against cardiovascular diseases (CVD). The priority of domestic scientists, in particular academician A.L. Myasnikov, in the development and creation of a combined drug for AH treatment is shown. The development of pharmacology and pharmaceutical technologies has allowed to expand the range of possible drug combinations for AH therapy, and the discovery of new pathophysiological mechanisms involved in the cardiovascular continuum has led to the understanding of the close links between AH and atherosclerosis. This fact prompted the scientific community to search for and implement in practice drug combinations that would allow multi-target therapy, that is, to influence several pathological processes and achieve a number of therapeutic goals. The presented review testifies to the transformation of the concept of fixed combinations for patients with AH into the concept of a multi-target drug. Multi-targeting is achieved not only by the pleotropic of components known as hypotensive agents, but also by combination with statins. Taking into account the wide AH prevalence in the population, its high medical and social significance, the critical importance as a risk factor for CVD, the authors consider a justified clinical and epidemiological approach to primary prevention of CVD with the widespread use of multi-targeted therapy in all high-risk patients with AH. It is expedient to develop new domestic medicines that implement the concept of a multi-targeted drug, to include them in the list of vital medicines, to increase the availability of these drugs to the population on the basis of preferential programs.

A Population-Based Study of Simvastatin Drug-Drug Interactions in Cardiovascular Disease Patients

Simvastatin is a commonly used medication for lipid management and cardiovascular disease, however, the risk of adverse events (AEs) with its use increases via drug-drug interaction (DDI) exposures. Patients were extracted if initially diagnosed with cardiovascular disease and newly initiated simvastatin therapy. The cohort was divided into a DDI-exposed group and a non-DDI exposed group. The DDI-exposed group was further divided into gemfibrozil, clarithromycin, and erythromycin exposure groups. The outcome was defined as a composite of predefined AEs. Our results show that the simvastatin-DDI group had a higher illness burden with longer simvastatin exposure time and more medical care follow-up compared with the simvastatin-non-DDI exposed group. AEs occurred more frequently in subjects exposed to interacting drugs with a higher risk for clarithromycin and erythromycin exposed subjects than for gemfibrozil subjects.

Statins: Pharmacokinetics, Pharmacodynamics and Cost-Effectiveness Analysis

Cardiovascular diseases secondary to atherosclerosis are the primary causes of early death and disability worldwide and dyslipidaemia represents one of the most important modifiable risk factors. Among lipid abnormalities that define it, low-density lipoprotein cholesterol (LDL-C) is the primary target of therapy, since multiple randomized controlled trials have shown the positive impact of its reduction on atherosclerosis development. For their ability to lower LDL-C levels, statins are the most studied drugs in cardiovascular disease prevention, of proven utility in slowing the progression or even determining regression of atherosclerosis. In addition, they have ancillary proprieties, with positive effects on the mechanisms involved in the development of atherosclerosis and cardiovascular morbidity and mortality, the so-called "pleiotropic mechanisms". Although sharing the same mechanism of action, the different chemical and pharmacological characteristics of each kind of statins affect their absorption, bioavailability, plasma protein binding properties, excretion and solubility. In this overview, we analysed pharmacokinetic and pharmacodynamic mechanisms of this class of drugs, specifying the differences among the molecules, along with the economic aspects. Detailed knowledge of characteristics and differences of each kind of available statin could help the physician in the correct choice, based also on patient's clinical profile, of this essential tool with a demonstrated high cost-effectiveness both in primary than in the secondary prevention of cardiovascular disease.

Effects of Ginkgo leaf tablets on the pharmacokinetics of atovastatin in rats

Context: Ginkgo leaf tablets (GLT), an effective traditional Chinese multi-herbal formula, are often combined with atorvastatin calcium (AC) for treating coronary heart disease in clinic. Objective: This study investigated the effects of GLT on the pharmacokinetics of AC and the potential mechanism. Materials and methods: The pharmacokinetics of AC (oral administered at a dose of 1 mg/kg) with or without pre-treatment of GLT (oral administered at a dose of 80 mg/kg/day for 10 days) were investigated in male Sprague-Dawley rats. The effects of GLT on the metabolic stability of AC were also investigated using rat liver microsome incubation systems. Results: The results indicated that the C_max increased from 36.84 ± 4.21 to 48.68 ± 6.35 ng/mL, and the AUC_(0-t) increased from 135.82 ± 21.05 to 77.28 ± 12.92 ng h/mL, and t_1/2 also increased from 2.62 ± 0.31 to 3.32 ± 0.57 h when GLT and AC were co-administered. The metabolic stability of AC was also increased (48.2 ± 6.7 vs. 36.7 ± 5.3 min) with the pre-treatment of GLT. Discussion: This study indicated that the main components in GLT could accelerate the metabolism of AC in rat liver microsomes and change the pharmacokinetic behaviours of AC. So these results showed that the herb-drug interaction between GLT and AC might occur, and the clinical efficacy could increase when they were co-administered. Therefore, the clinical dose of AC should be decreased when GLT and AC are co-administered.

Calcium Channel Blockers in Restoration of Endothelial Function: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Clinical evaluation of the Endothelial Function (EF) is becoming an essential step in the quality assessment of cardiovascular risk prevention and rational pharmacotherapy of cardiovascular disorders. The existing pieces of evidence suggested that Calcium Channel Blockers (CCB) can induce positive effects on impaired EF.

OBJECTIVE

To evaluate the effects of CCB on EF, we performed a meta-analysis of available data from randomized and placebo-controlled or other treatment-controlled clinical studies encompassing effects of CCB on EF, as measured by Flow-Mediated Dilation (FMD) of the brachial artery.

METHODS

The relevant clinical studies were searched by systematic exploration of the appropriate databases until November 30, 2017. A random-effect model was conducted. The primary outcome was the percentage change in FMD between the baseline and the final levels in response to investigated drugs.

RESULTS

Fifteen randomized clinical studies with 33 arms were identified. CCB improved FMD more pronounced than thiazide diuretics - TD (3 studies, 157 participants, WMD=2.08%, 95% CI=0.35-3.80%; P=0.02). Oppositely, ACE Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) notably improved FMD if compared to CCB (CCB vs. ACEI: 5 studies, 533 participants, WMD = -1.62%, 95% CI = -2.74% to -0.50%; P=0.005; and CCB vs. ARB: 9 studies, 669 participants, WMD = -1.52%, 95% CI = -2.22% to -0.81%; P=0.0001). CCB effects on EF were similar to those evoked by beta blockers or placebo.

CONCLUSION

CCB improved EF to a more prominent extent only if paralleled to TD, while inversely; ACEI and ARB were more effective in augmenting FMD.

Drug-related problems in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) patients are at risk of acquiring drug-related problems (DRPs). However, there has been a lack of studies on DRPs in patients with RA up to now.

METHOD

This retrospective study was conducted in a tertiary hospital in Malaysia from January 2012 to December 2017 with the purpose of assessing DRPs in RA patients and factors associated with its occurrence. A total of 200 patients who had received pharmacological treatment for RA were enrolled in this study. Assessment of DRPs was based on the Pharmaceutical Network Care Europe tool version 5.01.

RESULTS

A total of 289 DRPs with an average of 1.5±1.0 problems per patient were identified, in which 78.5% of the population had at least one DRP. The most common DRPs encountered were adverse reactions (38.8%), drug interactions (33.6%), and drug-choice problems (14.5%). Factors that had significant association with the occurrence of DRPs were polypharmacy (P=0.003), multiple comorbidities (P=0.001), hyperlipidemia (P=0.009), osteo (P=0.040), and renal impairment (P=0.044). These data indicated that the prevalence of DRPs was high among RA patients.

CONCLUSION

Early identification of types of DRPs and associated factors may enhance the prevention and management of RA.

Association between heat stroke and ischemic heart disease: A national longitudinal cohort study in Taiwan

The purpose of this study is to determine the relationship between heat stroke and ischemic heart disease (IHD), in a nationwide population using a longitudinal approach. We retrospectively examined the data from the National Health Insurance Research Database (NHIRD) in Taiwan, for patients examined between 2000 and 2013. In total, 628 patients with a heat stroke episode were enrolled and matched with 1256 patients without any history of a heat stroke episode by propensity score matching at a ratio of 1:2. The mean follow-up years of the heat stroke group was 11.89 years and the mean follow up of the control group was 11.51 years. An association between heat stroke episodes and IHD (log-rank p < .001) was found in a univariate cox regression analysis. After multivariate adjustment, age, comorbidities (hypertension, diabetes, stroke), and lower insurance premiums were associated with IHD events in patients who had a heat stroke. IHD was independently associated with heat stroke following cox multivariate regression analysis and patients with a heat stroke episode had a higher incidence of IHD events compared to those without any heat stroke episode (2598.41/10⁵ person-years vs. 1286.14/10⁵ person-years, adjusted hazard ratio 3.527, 95% CI: 2.078-4.032, p < .001). The onset of IHD in patients who suffered a heat stroke was earlier than in those without a heat stroke episode (2.08 ± 3.45 vs. 3.61 ± 3.25 years, p < .001). In conclusion, clinicians should be aware about evaluating the IHD risk following a heat stroke episode in a patient.

Effects of Danshen tablets on pharmacokinetics of atorvastatin calcium in rats and its potential mechanism

CONTEXT

Danshen tablets (DST), an effective traditional Chinese multi-herbal formula, are often combined with atorvastatin calcium (AC) for treating coronary heart disease in the clinic.

OBJECTIVE

This study investigated the effects of DST on the pharmacokinetics of AC and the potential mechanism.

MATERIALS AND METHODS

The pharmacokinetics of AC (1 mg/kg) with or without pretreatment of DST (100 mg/kg) were investigated using LC-MS/MS. The effects of DST (50 μg/mL) on the metabolic stability of AC were also investigated using rat liver microsome incubation systems.

RESULTS

The results indicated that C_max (23.87 ± 4.27 vs. 38.94 ± 5.32 ng/mL), AUC_(0-t) (41.01 ± 11.32 vs. 77.28 ± 12.92 ng h/mL), and t_1/2 (1.91 ± 0.18 vs. 2.74 ± 0.23 h) decreased significantly (p < 0.05) when DST and AC were co-administered, which suggested that DST might influence the pharmacokinetic behavior of AC when they are co-administered. The metabolic stability (t_1/2) of AC was also decreased (25.7 ± 5.2 vs. 42.5 ± 6.1) with the pretreatment of DST.

DISCUSSION AND CONCLUSIONS

This study indicated that the main components in DST could accelerate the metabolism of AC in rat liver microsomes and change the pharmacokinetic behaviors of AC. So these results showed that the herb-drug interaction between DST and AC might occur when they were co-administered. Therefore, the clinical dose of AC should be adjusted when DST and AC are co-administered.

Pedunculoside, a novel triterpene saponin extracted from Ilex rotunda, ameliorates high-fat diet induced hyperlipidemia in rats

Pedunculoside (PE) is a novel triterpene saponin extracted from the dried barks of Ilex rotunda Thunb. The present study aims to explore lipid-lowering effects of PE on hyperlipidemia rat induced by high-fat diet. The rats were fed with the high-fat diet and subjected to intragastric administration of PE at doses of 30, 15, or 5 mg/kg daily for 7 weeks. The results demonstrated that treatment with PE for 7-week dramatically decreased serum total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) and reduced liver TC in hyperlipidemia rat induced by high-fat diet. Furthermore, the results also showed that PE modulated the expression of enzymes involved in lipid metabolism including peroxisome proliferator-activated receptor α (PPAR-α), sterol regulatory element-binding protein 1 (SREBP-1), fatty acid synthase (FAS) and stearoyl CoA desaturase-1 (SCD-1) mRNA in liver. Besides, PE-treated group decreased weights and diameters of epididymal adipose hyperlipidemia rat. Mechanism study demonstrated that PE regulated PPAR-γ, CCAAT/Enhancer-binding Protein α (C/EBPα)、and SREBP-1 expression as well as inhibited phosphorylation of AMPK in MDI (methylisobutylxanthine, dexamethasone, insulin) induced-3T3L1 cells. Molecular Docking confirmed interaction between PE with proteins involving PPAR-γ, C/EBPα and SREBP-1. In summary, these findings may support that PE is a novel lipid-lowering drug candidate.

Risks of all-cause mortality and major kidney events in patients with new-onset primary open-angle glaucoma: a nationwide long-term cohort study in Taiwan

OBJECTIVE

Cardiovascular risk factors are associated with primary open-angle glaucoma (POAG) in the general population. However, long-term mortality and major kidney events in patients with new-onset POAG remain unclear.

METHODS

Using the Taiwan National Health Insurance Research Database between 1997 and 2011, 15 185 patients with a new diagnosis of POAG were enrolled and propensity score matched (1:1) with 15 185 patients without ocular disorders (WODs). All-cause mortality and major kidney events were analysed by a multivariate Cox proportional hazards regression model and a competing risk regression model.

RESULTS

The risk of all-cause mortality was significantly higher in patients with new-onset POAG than in those WODs (adjusted HR (aHR) 2.11, 95% CI 1.76 to 2.54; p<0.001). Patients with POAG had higher risks of acute renal failure (ARF) (competing risk aHR 2.58, 95% CI 1.88 to 3.55; p<0.001) and end-stage renal disease (ESRD) (competing risk aHR 4.84, 95% CI 3.02 to 7.77; p<0.001) than those WODs.

CONCLUSIONS

Our data demonstrate that POAG is a risk of all-cause mortality, ARF and ESRD, thus needing to notice mortality and major kidney events in patients with new-onset POAG.

Drug-Induced Kidney Injury in the Elderly

The incidence of acute kidney injury in the elderly has grown over the past decade. One of the primary drivers is drug-induced nephrotoxicity, which is the result of a combination of the unique susceptibilities to kidney injury and the increased use of medications in the elderly population. Specific drug classes are associated with increased rates of kidney injury including agents that block the renin angiotensin system, antimicrobials, and chemotherapeutic agents. Mechanistically, injury may be due to hemodynamic effects, tubular or glomerular toxicity, and interstitial nephritis. Early recognition of nephrotoxicity is critical, as are preventative steps when applicable. Unfortunately, treatment for established drug-induced kidney injury is limited and supportive care is required. Limiting exposure to nephrotoxic drugs is critical in decreasing the incidence of acute kidney injury in the elderly patient.

Compatibility of medication with PRISCUS criteria and identification of drug interactions in a large cohort of patients with COPD

Patients with COPD are often of advanced age and have a high number of medications due to their lung disease and comorbidities. Thus they are at risk for unwanted effects from drugs, either due to age or due to interactions between drugs. These issues are not clarified. We therefore assessed the number of medications and potential adverse effects in a large cohort of patients with COPD. The analysis was performed in 2741 patients of the German COPD cohort COSYCONET, using baseline data (visit 1) and follow-up data after about 1.5 years (visit 3). Spirometric GOLD grades 1-4 were found in 8/35/32/9% of patients and GOLD groups ABCD in 7/25/4/48% of patients, while the remaining patients (n = 450, 16.4%) could not be classified according to GOLD criteria. The compatibility of medication with age was evaluated via the PRISCUS list, drug interactions via the AiD clinic system, whereby only drug combinations occurring in at least 10 patients were considered (nine unwanted interactions, one wanted interaction). The median numbers of medications were 5 or more in all patient categories, among them 3 or more non-respiratory medications. In the total population there were 153 patients (10.2%) aged ≥65 years who had any medication of the PRISCUS list with intermediate or low risk. Serious adverse combinations of drugs according to AiD occurred in 114 patients (4.2%), while the number of unwanted but only potentially clinically relevant combinations was 175 (6.4%). The number of wanted combinations was 219 (8.0%). These numbers did not markedly change when restricting the analysis to patients of GOLD grades 1-4. Moreover, the results were similar for visit 1 and visit 3. We conclude that in a large cohort of COPD patients about 10% of patients aged at least 65 years had medications that could interfere with their age and that the proportions of patients with either unwanted or wanted drug interactions were both in the range of 8-10%. These results suggest that problems arising from the high number of medications were not very frequent in the COPD cohort analysed.

Drug-Drug Interactions between Atorvastatin and Dronedarone Mediated by Monomeric CYP3A4

Heterotropic interactions between atorvastatin (ARVS) and dronedarone (DND) have been deciphered using global analysis of the results of binding and turnover experiments for pure drugs and their mixtures. The in vivo presence of atorvastatin lactone (ARVL) was explicitly taken into account by using pure ARVL in analogous experiments. Both ARVL and ARVS inhibit DND binding and metabolism, while a significantly higher affinity of CYP3A4 for ARVL makes the latter the main modulator of activity (effector) in this system. Molecular dynamics simulations reveal significantly different modes of interactions of DND and ARVL with the substrate binding pocket and with a peripheral allosteric site. Interactions of both substrates with residues F213 and F219 at the allosteric site play a critical role in the communication of conformational changes induced by effector binding to productive binding of the substrate at the catalytic site.

Association Between Stroke Risk and Metformin Use in Hemodialysis Patients With Diabetes Mellitus: A Nested Case-Control Study

BACKGROUND

Metformin use reduces the incidence and severity of stroke in patients with type 2 diabetes mellitus (DM). The benefits of metformin for stroke have not been examined in hemodialysis patients with DM.

METHODS AND RESULTS

Using the National Health Insurance Research Database, we identified 17 760 patients with DM and new-onset hemodialysis between 2001 and 2013. Of these, 1898 patients hospitalized for either ischemic or hemorrhagic stroke were matched to 7592 control patients according to sex, age, and year of initial hemodialysis therapy by using incidence sampling. The association between metformin use and stroke risk was estimated using conditional logistic regression after adjustment for hemodialysis frequency, comorbidity, and prescribed medications. Metformin use was recorded before the date of stroke admission and the date of pseudostroke of the case and control patients, respectively. Results showed that hemodialysis patients with ischemic stroke were more likely to use metformin than the controls 1 year before the date of stroke admission (adjusted odds ratio: 1.64; 95% confidence interval, 1.32-2.04). The association was evident within 90 days before the index date (adjusted odds ratio: 1.81; 95% confidence interval, 1.27-2.60). The results were consistent with those of hemodialysis patients with hemorrhagic stroke. Metformin use remained a risk factor for stroke in patients treated with antihypertensive, sulfonylurea, and antiplatelet drugs.

CONCLUSIONS

This nested case-control study is the first to show that metformin use is associated with stroke risk in hemodialysis patients with DM. We suggest that metformin should not be used by hemodialysis patients with DM.

Severe Rhabdomyolysis due to Presumed Drug Interactions between Atorvastatin with Amlodipine and Ticagrelor

Atorvastatin and ticagrelor combination is a widely accepted therapy for secondary prevention of ischaemic heart disease. However, rhabdomyolysis is a well-known rare side effect of statins which should be considered when treatments are combined with cytochrome P450 3A4 enzyme inhibitors. We report a case of atorvastatin and ticagrelor associated severe rhabdomyolysis that progressed to multiorgan failure requiring renal replacement therapy, inotropes, intubation, and mechanical ventilation. Despite withdrawal of the precipitating cause and the supportive measures including renal replacement therapy, creatinine kinase increased due to ongoing rhabdomyolysis rapidly progressing to upper and lower limbs weakness. A muscle biopsy was performed to exclude myositis which confirmed extensive myonecrosis, consistent with statin associated rhabdomyolysis. After a prolonged ventilatory course in the intensive care unit, patient's condition improved with recovery from renal and liver dysfunction. The patient slowly regained her upper and lower limb function; she was successfully weaned off the ventilator and was discharged for rehabilitation. To our knowledge, this is a second case of statin associated rhabdomyolysis due to interaction between atorvastatin and ticagrelor. However, our case differed in that the patient was also on amlodipine, which is considered to be a weak cytochrome P450 3A4 inhibitor and may have further potentiated myotoxicity.

Pharmacogenetic Foundations of Therapeutic Efficacy and Adverse Events of Statins

Background: In the era of precision medicine, more attention is paid to the search for predictive markers of treatment efficacy and tolerability. Statins are one of the classes of drugs that could benefit from this approach because of their wide use and their incidence of adverse events. Methods: Literature from PubMed databases and bibliography from retrieved publications have been analyzed according to terms such as statins, pharmacogenetics, epigenetics, toxicity and drug–drug interaction, among others. The search was performed until 1 October 2016 for articles published in English language. Results: Several technical and methodological approaches have been adopted, including candidate gene and next generation sequencing (NGS) analyses, the latter being more robust and reliable. Among genes identified as possible predictive factors associated with statins toxicity, cytochrome P450 isoforms, transmembrane transporters and mitochondrial enzymes are the best characterized. Finally, the solute carrier organic anion transporter family member 1B1 (SLCO1B1) transporter seems to be the best target for future studies. Moreover, drug–drug interactions need to be considered for the best approach to personalized treatment. Conclusions: Pharmacogenetics of statins includes several possible genes and their polymorphisms, but muscular toxicities seem better related to SLCO1B1 variant alleles. Their analysis in the general population of patients taking statins could improve treatment adherence and efficacy; however, the cost–efficacy ratio should be carefully evaluated.

Drug Class Combination–Associated Acute Kidney Injury

Objective: To evaluate the quality of available evidence of drug class combinations and their association with the development of acute kidney injury (AKI). Data Sources: A search of MEDLINE and Embase databases was completed using the following terms: “risk factor AND (acute kidney injury or acute kidney failure) AND (drug or medication).” Study Selection and Data Extraction: Inclusion criteria were the following: English language, full-text availability, and at least 1 drug-combination. Each citation was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. The literature was evaluated using the quality of evidence component of GRADE. No standardized definition of AKI was applied throughout.. Data Synthesis: Out of 2139 total citations, 151 were assessed for full-text review, with 121 citations (6%) meeting inclusion criteria, producing76 unique drug class combinations. Overall, 56 combinations (73.7%) were considered very low quality; 12 (15.8%) were considered low quality. There were 8 (10.5%) of moderate quality, and no combination was considered high quality. 58 (76%) combinations that had a single citation,with a mean of 1.6 citations per drug class combination. The combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and diuretics was reported in 10 citations, the largest number of citations. Conclusions: Our study demonstrates a lack of well-designed studies addressing drug class combination–associated AKI. The combination of NSAIDs and diuretics with or without additional renin-angiotensin aldosterone agents had the strongest level of evidence. Despite limitations, the information included in this review may result in additional scrutiny about combining certain individual nephrotoxic drugs.