Possibility that certain hypnotics might cause cancer in skin

Association of sleep duration and sleeping pill use with mortality and life expectancy: A cohort study of 484,916 adults

OBJECTIVES

To compare mortality risk and life expectancy among individuals with different sleep durations and sleeping pill use.

METHODS

A cohort of 484,916 community-dwelling adults in Taiwan was recruited into a health screening program from 1994 to 2011. Subjects were categorized by daily sleep duration into 4 groups: extremely short (<4 hours), short (4-6 hours), medium (6-8 hours), and long (>8 hours). Cox proportional hazards models were used to investigate the associations of mortality risk with sleep duration and sleeping pill use. Models were adjusted for sociodemographic characteristics, lifestyle, and comorbidities. Life expectancy tables were calculated among sleeping pill users and nonusers with different sleep durations.

RESULTS

With 6- 8 hours of daily sleep, sleeping pill nonusers had the lowest mortality risk. Sleeping pill users, even with this optimal amount of sleep, had a 55% (p < .001, 95% CI, 1.38-1.73) higher mortality risk than nonusers. The life expectancy of 30-year-old male sleeping pill users with extremely short or long sleep durations was 12-13 years shorter than sleeping pill nonusers who had 6-8 hours of sleep. On average, life expectancy in individuals using sleeping pills (vs. nonusers) was shorter by 5.3 (95% CI, 4.10-6.32) years in men and 5.7 (95% CI, 5.28-7.98) years in women.

CONCLUSIONS

This study suggests that the use of sleeping pills is associated with an increased risk of mortality and shortened life expectancy, especially in extreme sleepers. Regular users should be aware of potential harms from sleeping pills.

Selecting a pharmacotherapy regimen for patients with chronic insomnia

INTRODUCTION

Chronic insomnia, whether it is primary or in combination with another medical or psychiatric disorder, is a prevalent condition associated with significant morbidity, reduced productivity, increased risk of accidents, and poor quality of life. Pharmacologic and behavioral treatments have equivalent efficacy with each having its own advantages and limitations.

AREAS COVERED

The purpose of this perspective is to delineate the limitations encountered in implementing cognitive behavioral therapy (CBT) and to review the pharmacological treatments designed to target the different phenotypes of insomnia. The discussions address how to choose the optimal medication or combination thereof based on patients' characteristics, available medications, and the presence of comorbid conditions. Selective nonbenzodiazepine sedative 'Z-drug' hypnotics, melatonin receptor agonist-ramelteon, and low-dose doxepin are the agents of choice for treatment of primary and comorbid insomnia.

EXPERT OPINION

A pharmacological intervention should be offered if cognitive behavioral therapy for insomnia is not available or has failed to achieve its goals. Increasing evidence of the significant adverse consequences of long-term benzodiazepines should limit the prescription of these agents to specific conditions. Testing novel dosing regimens with a combination of hypnotic classes augmented with CBT deserve further investigation.

Association between sedative-hypnotic medication use and incidence of cancer in Korean Nation Health Insurance Service data

OBJECTIVES

We aimed to investigate the association between the use of various sedative-hypnotics and the incidence of overall and individual cancers in a large, population-based, retrospective cohort study.

METHODS

We selected a 5% random sample of individuals aged 50 years or older from data maintained by the Korean National Health Insurance Service for the years 2002-2015, excluding individuals with a prior diagnosis of cancer and with any sedative-hypnotic use in the initial two years of follow-up, leaving 236,759 participants for the final analysis. Exposure to sedative-hypnotics was defined by type of drug, standardized to a defined daily dose, and coded as a time-varying variable. Cox proportional hazard models were applied after adjusting for sex, socio-economic status, and comorbidities.

RESULTS

We observed increased risk for overall cancer among men and women who used sedative-hypnotics (hazard ratio (HR) = 1.07, 95% confidence interval (CI) = 1.01-1.13 for men; HR = 1.21, 95% CI = 1.09-1.25 for women) compared with non-users after full adjustment. In the fully adjusted model, women with any sedative-hypnotic use had significantly increased risk for thyroid (HR = 1.53, 95% CI = 1.24-1.87), breast (HR = 1.29, 95% CI = 1.04-1.61), ovarian (HR = 1.65, 95% CI = 1.10-2.46), and lung cancer (HR = 1.40, 95% CI = 1.17-1.69) compared with non-users. Men with sedative-hypnotic use had increased risk for prostate (HR = 1.36, 95% CI = 1.16-1.58), brain (HR = 1.67, 95% CI = 1.04-2.69), and lung cancer (HR = 1.20, 95% CI = 1.07-1.35) compared with non-users.

CONCLUSION

We found a significant increase in overall cancer incidence among participants who used sedative-hypnotics, and both male and female sedative-hypnotic users had significantly increased risk for certain types of cancer.

Use of Sedative-Hypnotics and Mortality: A Population-Based Retrospective Cohort Study

STUDY OBJECTIVES

Researchers have previously reported a possible association between sedative-hypnotics and increased mortality. However, the relationship remains controversial. We investigated the association between sedative-hypnotics and mortality using a large population-based database from the Republic of Korea.

METHODS

We used a National Health Insurance Service database. The study population was a 5% random sample of the database from the years 2002- 2015. Individuals who were age 40 years and older were included in the analysis. The sedative-hypnotic users were defined as individuals prescribed 30 or more defined daily doses of sedative-hypnotics per year since January 2004. Sedative-hypnotics were classified based on type and total amount. We estimated the risk of mortality (death from January 2004 to December 2015) using time-dependent Cox regression model adjusted for age, sex, Charlson Comorbidity Index, and psychiatric comorbidity.

RESULTS

We identified 180,823 study participants who used sedative-hypnotics and 320,136 nonusers. In a multivariate model, study participants who used sedative-hypnotics had significantly higher mortality risk than nonusers (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.12-1.16). Specifically, study participants who used zolpidem had a higher mortality risk (HR 1.59, 95% CI 1.52-1.67) than nonusers.

CONCLUSIONS

Based on the current study results, sedative-hypnotics were associated with an increased risk of mortality, especially in study participants who used zolpidem.

Benzodiazepine-Associated Carcinogenesis: Focus on Lorazepam-Associated Cancer Biomarker Changes in Overweight Individuals

OBJECTIVE

Cellular, animal, and human epidemiological studies suggested that benzodiazepines increase the risk of cancer and cancer mortality. Obesity is also clearly linked to carcinogenesis. However, no human studies have examined benzodiazepine-associated carcinogenesis as assessed by changes in cancer biomarkers.

METHODS

A total of 19 patients were recruited, and received a 6-week treatment of 0.5 mg lorazepam. The measured cancer biomarkers were angiopoietin-2 (ANG-2), soluble CD40 ligand, epidermal growth factor, endoglin, soluble Fas ligand (sFASL), heparin-binding EGF-like growth factor (HB-EGF), insulin-like growth factor binding protein, interleukin (IL)-6, IL-8, IL-18, plasminogen activator inhibitor (PLGF), placental growth factor, transforming growth factor (TGF)-α, tumor necrosis factor (TNF)-α, urokinase-type plasminogen (uPA), vascular endothelial growth factor (VEGF)-A, VEGF-C, and VEGF-D.

RESULTS

Six cancer biomarkers were significantly increased in all patients as a whole. The subgroup analysis revealed a distinct pattern of change. Overweight patients showed a significant increase in 11 cancer biomarkers, including ANG-2, sFASL, HB-EGF, IL-8, PLGF, TGF-α, TNF-α, uPA, VEGF-A, VEGF-C, and VEGF-D. However, normal-weight patients did not show any changes in cancer biomarkers.

CONCLUSION

Adiposity may have primed the carcinogenic potential, leading to lorazepam-associated carcinogenesis in overweight patients. Epidemiological studies addressing this issue should consider the potential modulator contributing to benzodiazepine-associated carcinogenesis.

Sleep: important considerations for the prevention of cardiovascular disease

PURPOSE OF REVIEW

Sleep plays many roles in maintenance of cardiovascular health. This review summarizes the literature across several areas of sleep and sleep disorders in relation to cardiometabolic disease risk factors.

RECENT FINDINGS

Insufficient sleep duration is prevalent in the population and is associated with weight gain and obesity, inflammation, cardiovascular disease, diabetes, and mortality. Insomnia is also highly present and represents an important risk factor for cardiovascular disease, especially when accompanied by short sleep duration. Sleep apnea is a well-characterized risk factor for cardiometabolic disease and cardiovascular mortality. Other issues are relevant as well. For example, sleep disorders in pediatric populations may convey cardiovascular risks. Also, sleep may play an important role in cardiovascular health disparities.

SUMMARY

Sleep and sleep disorders are implicated in cardiometabolic disease risk. This review addresses these and other issues, concluding with recommendations for research and clinical practice.

Zolpidem Administration and Risk of Hepatocellular Carcinoma: A Case-Control Study in Taiwan

Background/Objectives: Previous studies showed that zolpidem use could be associated with increased cancer risk, but the role of zolpidem on hepatocellular carcinoma (HCC) risk remains undetermined. The study purpose was to examine the association between HCC risk and zolpidem use in Taiwan. Methods: Using the database from the Taiwan National Health Insurance Program, we designed a case-control study which consisted of 77986 subjects aged 20 years or older with newly diagnosed HCC as the case group, and 77986 subjects without HCC as the control group, from 2000 to 2011. Ever use of zolpidem was defined as a subject who had at least a prescription for zolpidem before the index date. Never use was defined as a subject who did not have a prescription for zolpidem before the index date. The association between HCC risk and zolpidem use was determined by the odds ratio (OR) and 95% confidence interval (CI) in a multivariable logistic regression model. Results: After adjustment for confounding factors, the adjusted OR of HCC was 1.05 (95% CI 0.97, 1.13) for subjects with ever use of zolpidem, compared with never use of zolpidem. The adjusted OR of HCC was 1.01 for subjects with increasing cumulative duration of zolpidem use for every 1 year (95% CI 0.99, 1.03), compared with never use of zolpidem. Conclusion: There is no significant association between HCC risk and zolpidem use. There is no duration-dependent effect of zolpidem use on HCC risk.

External adjustment of unmeasured confounders in a case-control study of benzodiazepine use and cancer risk

AIMS

Previous studies have reported diverging results on the association between benzodiazepine use and cancer risk.

METHODS

We investigated this association in a matched case-control study including incident cancer cases during 2002-2009 in the Danish Cancer Registry (n = 94 923) and age- and sex-matched (1:8) population controls (n = 759 334). Long-term benzodiazepine use was defined as ≥500 defined daily doses 1-5 years prior to the index date. We implemented propensity score (PS) calibration using external information on confounders available from a survey of the Danish population. Two PSs were used: The error-prone PS using register-based confounders and the calibrated PS based on both register- and survey-based confounders, retrieved from the Health Interview Survey.

RESULTS

Register-based data showed that cancer cases had more diagnoses, higher comorbidity score and more co-medication then population controls. Survey-based data showed lower self-rated health, more self-reported diseases, and more smokers as well as subjects with sedentary lifestyle among benzodiazepine users. By PS calibration, the odds ratio for cancer overall associated with benzodiazepine use decreased from 1.16 to 1.09 (95% confidence interval 1.00-1.19) and for smoking-related cancers from 1.20 to 1.10 (95% confidence interval 1.00-1.21).

CONCLUSION

We conclude that the increased risk observed in the solely register-based study could partly be attributed to unmeasured confounding.

Mortality Risk of Hypnotics: Strengths and Limits of Evidence

Sleeping pills, more formally defined as hypnotics, are sedatives used to induce and maintain sleep. In a review of publications for the past 30 years, descriptive epidemiologic studies were identified that examined the mortality risk of hypnotics and related sedative-anxiolytics. Of the 34 studies estimating risk ratios, odds ratios, or hazard ratios, excess mortality associated with hypnotics was significant (p < 0.05) in 24 studies including all 14 of the largest, contrasted with no studies at all suggesting that hypnotics ever prolong life. The studies had many limitations: possibly tending to overestimate risk, such as possible confounding by indication with other risk factors; confusing hypnotics with drugs having other indications; possible genetic confounders; and too much heterogeneity of studies for meta-analyses. There were balancing limitations possibly tending towards underestimates of risk such as limited power, excessive follow-up intervals with possible follow-up mixing of participants taking hypnotics with controls, missing dosage data for most studies, and over-adjustment of confounders. Epidemiologic association in itself is not adequate proof of causality, but there is proof that hypnotics cause death in overdoses; there is thorough understanding of how hypnotics euthanize animals and execute humans; and there is proof that hypnotics cause potentially lethal morbidities such as depression, infection, poor driving, suppressed respiration, and possibly cancer. Combining these proofs with consistent evidence of association, the great weight of evidence is that hypnotics cause huge risks of decreasing a patient's duration of survival.

Use of Zolpidem and Risk of Acute Pyelonephritis in Women: A Population-Based Case-Control Study in Taiwan

The aim of this study was to assess a possible correlation between zolpidem use and acute pyelonephritis (APN) in women in Taiwan. Therefore, we performed a case-control study involving the Taiwan's National Health Insurance Research Database between 2000 and 2011. This study included 3151 female participants aged 20 to 84 years who experienced the first bout of APN (case group) and 6015 randomly selected female participants without APN (control group). Zolpidem use was defined as "current," "early," or "late," if the last remaining 1 tablet for zolpidem was detected within 7 days, between 8 and 14 days, or ≥15 days before the date of APN diagnosis, respectively. The multivariable unconditional logistic regression model was used to calculate the odds ratios (ORs) with 95% confidence intervals (CIs) to assess the correlation between zolpidem use and APN. After adjusting for confounders, the multivariable analysis yielded an adjusted APN OR of 2.2 for participants with current zolpidem use (95%CI 1.7-2.8) compared with participants who never used zolpidem. The adjusted ORs gradually decreased to 1.4 for participants with early zolpidem use (95%CI 0.8-2.5) and 1.1 for participants with late zolpidem use (95%CI 0.9-1.2), but without statistical significance. Only patients with current zolpidem use had a significantly increased relative risk of APN. Additional large confirmatory studies are needed to illustrate a causal relationship. Meanwhile, physicians and pharmacists should be more cautious about the risk of APN when prescribing and dispensing zolpidem in women.

Diagnosis and Treatment of Insomnia Comorbid with Obstructive Sleep Apnea

Insomnia is often comorbid with obstructive sleep apnea. It reduces positive airway pressure (PAP) therapy acceptance and adherence. Comorbid patients show greater daytime impairments and poorer health outcomes. The insomnia often goes undiagnosed, undertreated, or untreated. Pharmacotherapy is not recommended for long-term treatment. Although care should be taken administering behavioral therapies to patients with elevated sleepiness, cognitive behavior therapy for insomnia (CBTi) is an effective and durable nondrug therapy that reduces symptoms and may increase the effectiveness of PAP therapy. Sleep clinics should be alert to comorbid insomnia and provide adequate diagnostic tools and clinicians with CBTi expertise.

Mortality associated with anxiolytic and hypnotic drugs-A systematic review and meta-analysis

BACKGROUND

Use of hypnotics or anxiolytic drugs is common and various studies have reported increased mortality with hypnotics or anxiolytic use.

OBJECTIVE

To consolidate the evidence on mortality risk associated with hypnotics or anxiolytic use

METHODS

Major databases were searched through April 2014 for studies reporting mortality risk associated with hypnotics or anxiolytics use. A pooled hazard ratio with 95% confidence interval was estimated using random-effects model.

RESULTS

After screening 2188 articles, 25 studies (24 cohort, 1 case-control) enrolling 2,350,093 patients with 59% females (age 18-102 years) were included in the meta-analysis. Hypnotics or anxiolytic users had 43% higher risk of mortality than non-users (hazard ratio, 1.43; 95% confidence interval, [1.12, 1.84]). Eight studies reported risk estimates for each gender category and pooled results from these studies showed increased risk of mortality among men (hazard ratio = 1.60, 95% confidence interval = [1.29,1.99]) and women (hazard ratio = 1.68, 95% confidence interval = [1.38, 2.04]). Pooled results from 10 studies showed higher mortality among benzodiazepine users compared to non-users (hazard ratio = 1.60, 95% confidence interval = [1.03, 2.49]), while pooled results from five studies showed an increased risk of mortality with Z-drugs use although the effect could not reach statistical significance (hazard ratio = 1.73, 95% confidence interval = [0.95, 3.16]). Significant heterogeneity was observed in the analyses and the quality of included studies was good.

CONCLUSION

This meta-analysis suggests that hypnotics or anxiolytics drugs use is associated with increased mortality and hence should be used with caution. Future studies focused on underlying mechanism of increased mortality with hypnotics or anxiolytics use are required.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). This review includes new information on the growing USA overdose epidemic, eight new epidemiologic studies of hypnotics' mortality not available for previous compilations, and new emphasis on risks of short-term hypnotic prescription. The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. The short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics are usually prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders might offer safer and more effective alternative approaches to insomnia.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits. Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality (especially overdose deaths, quiet deaths at night, and suicides), infections, cancer, depression, automobile crashes, falls, other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with even greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse (not better) and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.

Is suvorexant a better choice than alternative hypnotics?

Suvorexant is a novel dual orexin receptor antagonist (DORA) newly introduced in the U.S. as a hypnotic, but no claim of superiority over other hypnotics has been offered.  The manufacturer argued that the 5 and 10 mg starting doses recommended by the FDA might be ineffective.  The manufacturer's main Phase III trials had not even included the 10 mg dosage, and the 5 mg dosage had not been tested at all in registered clinical trials at the time of approval.  Popular alternative hypnotics may be similarly ineffective, since the FDA has also reduced the recommended doses for zolpidem and eszopiclone.  The "not to exceed" suvorexant dosage of 20 mg does slightly increase sleep.  Because of slow absorption, suvorexant has little effect on latency to sleep onset but some small effect in suppressing wakening after sleep onset and in improving sleep efficiency. The FDA would not approve the manufacturer's preferred 40 mg suvorexant dosage, because of concern with daytime somnolence, driving impairment, and possible narcolepsy-like symptoms.  In its immediate benefits-to-risks ratio, suvorexant is unlikely to prove superior to currently available hypnotics—possibly worse—so there is little reason to prefer over the alternatives this likely more expensive hypnotic less-tested in practice.  Associations are being increasingly documented relating hypnotic usage with incident cancer, with dementia risks, and with premature death.  There is some basis to speculate that suvorexant might be safer than alternative hypnotics in terms of cancer, dementia, infections, and mortality.  These safety considerations will remain unproven speculations unless adequate long-term trials can be done that demonstrate suvorexant advantages.

Use of sleep medications and risk of cancer: a matched case-control study

BACKGROUND

Previous research suggests a possible link between sleep-medication use and mortality, especially cancer deaths, but findings are mixed, and large population-based studies are lacking.

METHODS

Data from the Finnish Public Sector study were linked to the Finnish Cancer Register and the Drug Prescription Register of Finland. A total of 5053 cancer cases (mean age of 57.4 years) diagnosed in 2002-2011, and their 24,388 controls free of cancer and matched for sex, age, socioeconomic status, employer, and geographical area, were identified. The use of sleep medications was defined as purchases of prescribed sleep medications.

RESULTS

Both quantity and duration of prior sleep-medication use during the seven years studied were associated with increased odds of having cancer. Compared with participants not using sleep medications, the odds ratio was 1.18-fold (95% confidence interval (CI): 1.01-1.39) for those who used >100 defined daily doses per year and 1.16-fold (95% CI: 1.01-1.34) for those who had such a medication for >3 years. Site-specific analyses showed a more pronounced association of quantity and duration of sleep-medication use with subsequent cancer of the respiratory system (odds ratio for >100 defined daily doses per year vs. no use: 3.47; 95% CI: 1.97-6.11). No associations were found with other cancer sites.

CONCLUSION

In this register-based study, sleep-medication use was associated with an increased cancer incidence of the respiratory system. Further studies are needed to examine potential carcinogenic mechanisms associated with hypnotic medications.

Use of Sleep Medications and Mortality: The Hordaland Health Study

Background

Previous research suggests a possible link between the use of sleep medications and mortality, but findings are mixed and well-controlled community-based studies are lacking.

Objective

The aim of the current study was to examine the prospective association between sleep medications and all-cause mortality.

Method

Using a cohort design with 13–15 years of follow-up, we linked self-reported medication use and data on possible confounders from the Hordaland Health Study (HUSK N = 21,826) obtained over the period 1997–1999 to mortality data from the Norwegian Cause of Death Registry. Users of sleep medications (n = 159) were defined as those reporting intake of any prescribed sleep medication (coded according to the Anatomical Therapeutic Chemical [ATC] classification system) on the day before participation in HUSK. Users of sleep medications were also asked if their intake was on a daily or a non-daily basis. Analyses presented are adjusted for sociodemographic and lifestyle factors, mental and physical health, and other medication use.

Results

We found that both type and frequency of sleep medication use were associated with increased general mortality risk. Compared with participants not using sleep medications, those who reported any use had a twofold risk for mortality (95 % confidence interval [CI] 1.1–3.7); the hazard ratio (HR) was 2.9 (95 % CI 1.4–5.9) for daily and 1.1 (95 % CI 0.3–3.4) for non-daily users. Mortality risk was higher for benzodiazepines (HR 3.1; 95 % CI 1.3–7.6), but not significant for short-acting benzodiazepine agonists (HR 1.5; 95 % CI 0.7–3.5).

Conclusion

Community dwellers who use sleep medications, particularly benzodiazepines, had a significantly increased risk of dying during the 13–15 years of follow-up. The low numbers of individuals reporting chronic usage indicate that the data should be interpreted with great caution, and more well-controlled studies with registry-based information on sleep medication use are needed to further examine the potential harmful effects of sleep medications.

Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study

OBJECTIVE

To test the hypothesis that people taking anxiolytic and hypnotic drugs are at increased risk of premature mortality, using primary care prescription records and after adjusting for a wide range of potential confounders.

DESIGN

Retrospective cohort study.

SETTING

273 UK primary care practices contributing data to the General Practice Research Database.

PARTICIPANTS

34,727 patients aged 16 years and older first prescribed anxiolytic or hypnotic drugs, or both, between 1998 and 2001, and 69,418 patients with no prescriptions for such drugs (controls) matched by age, sex, and practice. Patients were followed-up for a mean of 7.6 years (range 0.1-13.4 years).

MAIN OUTCOME

All cause mortality ascertained from practice records.

RESULTS

Physical and psychiatric comorbidities and prescribing of non-study drugs were significantly more prevalent among those prescribed study drugs than among controls. The age adjusted hazard ratio for mortality during the whole follow-up period for use of any study drug in the first year after recruitment was 3.46 (95% confidence interval 3.34 to 3.59) and 3.32 (3.19 to 3.45) after adjusting for other potential confounders. Dose-response associations were found for all three classes of study drugs (benzodiazepines, Z drugs (zaleplon, zolpidem, and zopiclone), and other drugs). After excluding deaths in the first year, there were approximately four excess deaths linked to drug use per 100 people followed for an average of 7.6 years after their first prescription.

CONCLUSIONS

In this large cohort of patients attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.

A Hindi version of the Composite Scale of Morningness

BACKGROUND

Several pen and paper measures of human circadian preference are available in English, but none are available in Hindi, hampering research in circadian behavior among Hindi speaking populations in India and elsewhere. The present study describes a Hindi version of the Composite Scale of Morningness (CSM), a self-reported questionnaire widely used to assess morningness/eveningness (M/E). M/E has been used a proxy for circadian phase in lieu of cumbersome and expensive laboratory studies.

METHOD

The thirteen item English version of the CSM was translated into Hindi and independently back translated into English. Inconsistencies between the original and back translated versions were then resolved. Both versions were next administered to bilingual persons at Delhi, India (N=130). After intra-class correlations between the Hindi and the English versions were examined, the Hindi version was administered to community based participants representing different age groups (N=310).

RESULTS

There was satisfactory intra-class correlation (ICC) between the total scores for the Hindi and the English versions of the CSM (Cronbach's alpha=0.873), with variation for individual items scores. Total CSM scores in the second sample suggested a significant association with age, consistent with published reports with the English CSM, i.e., morningness tendencies were more likely to be reported by older adults. Significant associations with gender or educational status were not observed.

CONCLUSIONS

The Hindi CSM is a brief questionnaire that provides behavioral measures of diurnal preference. It is freely available for research in Hindi speaking populations.

Use of benzodiazepines or benzodiazepine related drugs and the risk of cancer: a population-based case-control study

AIM

Studies of the carcinogenic potential of benzodiazepines and related drugs (BZRD) have been equivocal. A recent study reported a 35% excess cancer risk among users of hypnotics, including benzodiazepines.

METHOD

Using Danish nationwide registers, we conducted a matched case-control study of the association between BZRD and cancer risk. During 1 January 2002 and 31 December 2009, we identified 152 510 cases with a first time cancer who were matched (1:8) by age and gender to 1,220,317 cancer-free controls. A new-user design was applied by excluding all subjects who had used anxiolytics, hypnotics or sedatives during the first 2 years of available prescription data (1995-6). Odds ratios (ORs) with 95% confidence intervals (CI) were estimated using conditional logistic regression, adjusting for potential confounders. In the primary analysis, long term use of BZRD was defined by a cumulative amount of ≥500 defined daily doses of BZRD within a period of 1 to 5 years prior to the index date.

RESULTS

The adjusted OR for cancer associated with BZRD use was 1.09 (95% CI 1.04, 1.14). ORs were close to unity for most cancer sites, except stomach 1.40 (95% CI 1.05, 1.88), oesophagus 1.43 (95% CI 1.01, 2.02), liver 1.81 (95% CI 1.18, 2.80), lung 1.38 (95% CI 1.23, 1.54), pancreas 1.35 (95% CI 1.02, 1.79) and kidney 1.39 (95% CI 1.01, 1.91). For tobacco-related cancers, the OR was 1.15 (95% CI 1.09, 1.22) and for the remaining cancer sites 1.01 (95% CI 0.94, 1.08). Sub-group analyses revealed only small differences between different levels of exposure or different patient subgroups.

CONCLUSION

BZRD use was not associated with an overall increase in cancer risk, except for what is likely explained by minor lifestyle confounding, e.g. smoking.

Relationship of zolpidem and cancer risk: a Taiwanese population-based cohort study

OBJECTIVE

To evaluate the relationship between the use of zolpidem and subsequent cancer risk in Taiwanese patients.

METHODS

We used data from the National Health Insurance system of Taiwan to investigate whether use of zolpidem was related to cancer risk. For the study cohort, we identified 14,950 patients who had received a first prescription for zolpidem from January 1, 1998, through December 31, 2000. For each zolpidem user, we selected randomly 4 comparison patients without a history of using zolpidem who were frequency-matched by sex, age, and year of the index date. Incidence rates of all cancers and selected site-specific cancers were measured by the end of 2009, and related hazard ratios (HRs) and 95% confidence intervals (CIs) of the cancer were measured as well.

RESULTS

The risk of developing any cancer was greater in patients using zolpidem than in nonusers (HR, 1.68; 95% CI, 1.55-1.82). The stratified analysis showed that the overall HR for high-dosage zolpidem (≥300 mg/y) was 2.38. The site-specific cancer risk was the highest for oral cancer (HR, 2.36; 95% CI, 1.57-3.56), followed by kidney cancer, esophageal cancer, breast cancer, liver cancer, lung cancer, and bladder cancer (HR, 1.60; 95% CI, 1.06-2.41). Men were at higher risk than women.

CONCLUSION

This population-based study revealed some unexpected findings, suggesting that the use of zolpidem may be associated with an increased risk of subsequent cancer. Further large-scale and in-depth investigations in this area are warranted.

Cohort study of the association of hypnotic use with mortality in postmenopausal women

OBJECTIVE

Previous studies found an association between hypnotic use and mortality risk. The prospective outcome data and the many baseline risk factors included in the Women's Health Initiative (WHI) provide an opportunity to better understand the reasons for this association.

SETTING

The WHI is a long-term national health study that focused on strategies for preventing disease in postmenopausal women. Participants were enrolled from 1993 to 1998.

DESIGN

Baseline hypnotic use was evaluated for an association with subsequent mortality or disease after adjusting for baseline risk.

SUBJECTS

148 938 postmenopausal women between the ages of 50 and 79 throughout the USA. The median follow-up was 8 years.

MAIN OUTCOME MEASURES

Mortality. Secondary outcomes included myocardial infarction, stroke, diabetes and seven types of cancer.

RESULTS

For persons who use hypnotic medications almost daily the age-adjusted hazard ratio (HR) for mortality was 1.62 (95% CI 1.50 to 1.74). Greater hypnotic use was associated with less healthy levels of physical function, general health and smoking at baseline. After adjustment for these factors the HR for almost daily hypnotic use was 1.14 (1.06 to 1.23) for mortality and 1.53 (1.18 to 1.99) for melanoma; it was not significantly associated with increased incidence of other diseases tested. Less frequent hypnotic use and several types of sleeping difficulties were not associated with mortality, but sleeping more than 10 h a night had a risk-adjusted HR for mortality of 1.28 (1.01 to 1.61).

CONCLUSIONS

The association of hypnotic use with mortality and incident disease was greatly reduced after adjusting for baseline risk factors. These findings do not support a strong independent association of hypnotic use with most health outcomes.

Hypnotics' association with mortality or cancer: a matched cohort study

OBJECTIVES

An estimated 6%-10% of US adults took a hypnotic drug for poor sleep in 2010. This study extends previous reports associating hypnotics with excess mortality.

SETTING

A large integrated health system in the USA.

DESIGN

Longitudinal electronic medical records were extracted for a one-to-two matched cohort survival analysis.

SUBJECTS

Subjects (mean age 54 years) were 10 529 patients who received hypnotic prescriptions and 23 676 matched controls with no hypnotic prescriptions, followed for an average of 2.5 years between January 2002 and January 2007.

MAIN OUTCOME MEASURES

Data were adjusted for age, gender, smoking, body mass index, ethnicity, marital status, alcohol use and prior cancer. Hazard ratios (HRs) for death were computed from Cox proportional hazards models controlled for risk factors and using up to 116 strata, which exactly matched cases and controls by 12 classes of comorbidity.

RESULTS

As predicted, patients prescribed any hypnotic had substantially elevated hazards of dying compared to those prescribed no hypnotics. For groups prescribed 0.4-18, 18-132 and >132 doses/year, HRs (95% CIs) were 3.60 (2.92 to 4.44), 4.43 (3.67 to 5.36) and 5.32 (4.50 to 6.30), respectively, demonstrating a dose-response association. HRs were elevated in separate analyses for several common hypnotics, including zolpidem, temazepam, eszopiclone, zaleplon, other benzodiazepines, barbiturates and sedative antihistamines. Hypnotic use in the upper third was associated with a significant elevation of incident cancer; HR=1.35 (95% CI 1.18 to 1.55). Results were robust within groups suffering each comorbidity, indicating that the death and cancer hazards associated with hypnotic drugs were not attributable to pre-existing disease.

CONCLUSIONS

Receiving hypnotic prescriptions was associated with greater than threefold increased hazards of death even when prescribed <18 pills/year. This association held in separate analyses for several commonly used hypnotics and for newer shorter-acting drugs. Control of selective prescription of hypnotics for patients in poor health did not explain the observed excess mortality.

Mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey

OBJECTIVE

Although widely used in the general population, sleeping pills and minor tranquilizers, also known as antianxiety agents, have been associated with undesirable outcomes. Reports about the association of these drugs with an elevated mortality rate are inconsistent and controversial. This study was designed to assess the mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey in Canada. It was hypothesized that anxiolytic and hypnotic drug use would be associated with an elevated mortality hazard.

METHOD

A population-based sample of 14 117 people aged 18 to 102 years participated in a longitudinal panel survey, with data collected every second year from 1994 to 2007. The primary outcome measures reported in this study are self-report use of anxiolytic and hypnotic drugs, and death.

RESULTS

For respondents who reported anxiolytic or hypnotic drug use in the past month the odds of mortality were 3.22 times more (95% CI 2.70 to 3.84) than for those who did not use anxiolytic or hypnotic drugs in the past month. After controlling for confounding sociodemographic, lifestyle, and health factors (including depression), the odds ratio was reduced to 1.36 (95% CI 1.09 to 1.70) but remained significant.

CONCLUSION

Sedative drug use is associated with a small but significant increase in mortality risk. Further research is required to confirm the mechanisms by which sedative drug use increases mortality risk. Where possible, physicians should systematically consider possibilities for nonpharmacological treatment of sleep disturbances and anxiety.

The association between insomnia and cardiovascular diseases

Insomnia, the most common sleep complaint in the general population, is defined by difficulty initiating or maintaining sleep, or nonrestorative sleep, accompanied by some form of daytime impairment. In the current review, we present an overview of recent studies on the association between insomnia and cardiovascular disease. It can be concluded that there is growing evidence for the hypothesis that insomnia is associated with an increased risk for cardiovascular disease independently of classic coronary risk factors. Furthermore, insomnia is likely to be associated with hypertension and elevated resting heart rate, both known to lead to cardiovascular disease. However, the existing evidence is not totally consistent and most findings have not been replicated unequivocally. The major limitations of the cited studies include the failure to use state-of-the-art criteria for insomnia diagnosis, the failure to control for depression, and the use of hypnotic medication and sleep apnea as potential confounders. However, the results suggest that insomnia is associated with an increased risk for cardiovascular disease mediated by hypertension or elevated resting heart rate. Consequently, more effort should be dedicated to cope with the high prevalence of insomnia in the general population.

Aggressive chronic platelet inhibition with prasugrel and increased cancer risks: revising oral antiplatelet regimens?

The TRITON-TIMI 38 was a head-to-head trial to assess the efficacy and safety of the experimental antiplatelet agent prasugrel vs. standard care with clopidogrel on top of aspirin. Besides some ischemic protection at expense of overwhelming bleeding disadvantage, prasugrel treated patients experienced three times higher rate of colonic neoplasms then after clopidogrel, and this difference was significant. Importantly, known gastrointestinal bleeding preceded the diagnosis of colonic neoplasms only in half of the patients. Three potential mechanisms responsible for such harmful association are reviewed, namely: (i) direct hazard of the experimental drug on cancer occurrence and progression; (ii) indirect modulation of tumor growth; and (iii) enhanced metastatic dissemination due to instability of platelet-tumor cell aggregates, or/and inability to keep the disease locally due by much more potent long-term platelet inhibition should be considered. Significant excess of cancer after prasugrel is alarming, and can be reasonably explained, with critical clinical implications not only for prasugrel further development, but also for existing and future chronic antiplatelet strategies. If the hypothesis that oral aggressive platelet inhibition cause higher cancer risks will turn out to be true, then intensity of platelet inhibition, and especially duration of chronic antiplatelet therapy should be reconsidered. More delicate platelet inhibition, and shorter exposure to oral antiplatelet agents will prevail.