Incidence of outpatient physician claims for upper gastrointestinal symptoms among new users of celecoxib, ibuprofen, and naproxen in an insured population in the United States

Large-scale evidence generation and evaluation across a network of databases for type 2 diabetes mellitus (LEGEND-T2DM): a protocol for a series of multinational, real-world comparative cardiovascular effectiveness and safety studies

INTRODUCTION

Therapeutic options for type 2 diabetes mellitus (T2DM) have expanded over the last decade with the emergence of cardioprotective novel agents, but without such data for older drugs, leaving a critical gap in our understanding of the relative effects of T2DM agents on cardiovascular risk.

METHODS AND ANALYSIS

The large-scale evidence generations across a network of databases for T2DM (LEGEND-T2DM) initiative is a series of systematic, large-scale, multinational, real-world comparative cardiovascular effectiveness and safety studies of all four major second-line anti-hyperglycaemic agents, including sodium-glucose co-transporter-2 inhibitor, glucagon-like peptide-1 receptor agonist, dipeptidyl peptidase-4 inhibitor and sulfonylureas. LEGEND-T2DM will leverage the Observational Health Data Sciences and Informatics (OHDSI) community that provides access to a global network of administrative claims and electronic health record data sources, representing 190 million patients in the USA and about 50 million internationally. LEGEND-T2DM will identify all adult, patients with T2DM who newly initiate a traditionally second-line T2DM agent. Using an active comparator, new-user cohort design, LEGEND-T2DM will execute all pairwise class-versus-class and drug-versus-drug comparisons in each data source, producing extensive study diagnostics that assess reliability and generalisability through cohort balance and equipoise to examine the relative risk of cardiovascular and safety outcomes. The primary cardiovascular outcomes include a composite of major adverse cardiovascular events and a series of safety outcomes. The study will pursue data-driven, large-scale propensity adjustment for measured confounding, a large set of negative control outcome experiments to address unmeasured and systematic bias.

ETHICS AND DISSEMINATION

The study ensures data safety through a federated analytic approach and follows research best practices, including prespecification and full disclosure of results. LEGEND-T2DM is dedicated to open science and transparency and will publicly share all analytic code from reproducible cohort definitions through turn-key software, enabling other research groups to leverage our methods, data and results to verify and extend our findings.

Increased Post-procedural Non-gastrointestinal Adverse Events After Outpatient Colonoscopy in High-risk Patients

BACKGROUND & AIMS

The incidence and predictors of non-gastrointestinal (GI) adverse events (AEs) after colonoscopy are not well-understood. We studied the effects of antithrombotic agents, cardiopulmonary comorbidities, and age on risk of non-GI AEs after colonoscopy.

METHODS

We performed a retrospective longitudinal analysis to assess the diagnosis, procedure, and prescription drug codes in a United States commercial claims database (March 2010-March 2012). Data from patients at increased risk (n = 82,025; defined as patients with pulmonary comorbidities or cardiovascular disease requiring antithrombotic medications) were compared with data from 398,663 average-risk patients. In a 1:1 matched analysis, 51,932 patients at increased risk, examined by colonoscopy, were compared with 51,932 matched (on the basis of age, sex, and comorbidities) patients at increased risk who did not undergo colonoscopy. We tracked cardiac, pulmonary, and neurovascular events 1-30 days after colonoscopy.

RESULTS

Thirty days after outpatient colonoscopy, non-GI AEs were significantly higher in patients taking antithrombotic medications (7.3%; odds ratio [OR], 10.75; 95% confidence interval, 10.13-11.42) or those with pulmonary comorbidities (1.8%; OR, 2.44; 95% confidence interval, 2.27-2.62) vs average-risk patients (0.7%) and in patients 60-69 years old (OR, 2.21; 95% confidence interval, 2.01-2.42) or 70 years or older (OR, 6.45; 95% confidence interval, 5.89-7.06), compared with patients younger than 50 years. The 30-day incidence of non-GI AEs in patients at increased risk who underwent colonoscopy was also significantly higher than in matched patients at increased risk who did not undergo colonoscopy in the anticoagulant group (OR, 2.31; 95% confidence interval, 2.01-2.65) and in the chronic obstructive pulmonary disease group (OR, 1.33; 95% confidence interval, 1.13-1.56).

CONCLUSIONS

Increased number of comorbidities and older age (older than 60 years) are associated with increased risk of non-GI AEs after colonoscopy. These findings indicate the importance of determining comorbid risk and evaluating antithrombotic management before colonoscopy.

Systematic Analysis of Adverse Event Reports for Sex Differences in Adverse Drug Events

Increasing evidence has shown that sex differences exist in Adverse Drug Events (ADEs). Identifying those sex differences in ADEs could reduce the experience of ADEs for patients and could be conducive to the development of personalized medicine. In this study, we analyzed a normalized US Food and Drug Administration Adverse Event Reporting System (FAERS). Chi-squared test was conducted to discover which treatment regimens or drugs had sex differences in adverse events. Moreover, reporting odds ratio (ROR) and P value were calculated to quantify the signals of sex differences for specific drug-event combinations. Logistic regression was applied to remove the confounding effect from the baseline sex difference of the events. We detected among 668 drugs of the most frequent 20 treatment regimens in the United States, 307 drugs have sex differences in ADEs. In addition, we identified 736 unique drug-event combinations with significant sex differences. After removing the confounding effect from the baseline sex difference of the events, there are 266 combinations remained. Drug labels or previous studies verified some of them while others warrant further investigation.

Upper gastrointestinal symptoms in patients treated with nonsteroidal anti-inflammatory drugs: prevalence and impact--the COMPLAINS study

OBJECTIVES

To investigate the prevalence and type of upper gastrointestinal symptoms during nonsteroidal anti-inflammatory drug (NSAID) therapy, the impact of these symptoms on daily life and adherence to treatment and the concordance between physicians' and patients' assessments.

METHODS

A sample of 1000 French rheumatologists was invited to participate in the study, of which 630 accepted. Participating physicians enrolled all patients above 18 years of age seen during a 1-week period who had been receiving daily NSAID treatment for at least 3 days (n = 8269). Data on gastrointestinal symptoms were collected using a standardized questionnaire. In the first two symptomatic patients seen by each physician, patient and physician questionnaires were used to investigate concordance between symptom evaluations.

RESULTS

Two thousand seven hundred and ninety-nine patients (33.8%) reported upper gastrointestinal symptoms; of these, 1056 (12.8% of the total population) had acid reflux symptoms (heartburn and/or acid regurgitation). The most common symptoms were epigastric burning (17.3%) and epigastric discomfort or pain (14.4%). Symptoms were less common with coxibs than with nonselective NSAIDs (26.4 vs. 35.4%, P<10). There was moderate or good agreement between physicians' and patients' symptom assessments. Upper gastrointestinal symptoms resulted in NSAID dose reduction in 5.8% of patients, temporary withdrawal of treatment in 17.2% and permanent withdrawal in 10.8%. Half of the patients reported at least moderate impairment of daily activities because of their symptoms.

CONCLUSION

Approximately, one-third of NSAID-treated patients complained of upper gastrointestinal symptoms, with coxibs being better tolerated than nonselective NSAIDs. These symptoms have a marked impact on the quality of life and adherence to therapy.

Cost-utility of celecoxib use in different treatment strategies for osteoarthritis and rheumatoid arthritis from the Quebec healthcare system perspective

OBJECTIVE

To assess the cost-utility of celecoxib in three treatment strategies for arthritis in Quebec, considering both upper gastrointestinal (GI) and cardiovascular (CV) events.

METHODS

A Markov analytic framework was used to model patients with osteoarthritis and rheumatoid arthritis at low/average and high risk of GI and CV toxicity over 5 years with monthly cycles. Treatment strategies were modelled in line with Canadian clinical practice. In first-line treatment, patients started on celecoxib; second-line, patients started on a non-selective non-steroidal anti-inflammatory drug (NSAID) and switched to celecoxib after a first GI event; third-line, patients started on a non-selective NSAID, added a proton pump inhibitor (PPI) after a first GI event, and switched to celecoxib after a second GI event (while maintaining the PPI). Model inputs were determined through comprehensive literature searches (MEDLINE and EMBASE) from 1995 to 2006. Included studies evaluated GI (dyspepsia, uncomplicated and complicated ulcers, death) and CV (myocardial infarction, stroke, death) events. Drug and procedure costs were derived from Canadian published sources (Can$2005).

RESULTS

Total costs per patient for celecoxib first-, second-, and third-line treatment were Can$4,790, $3,390, and $3,466, and total quality-adjusted life-years (QALY) were 3.251, 3.231, and 3.230, respectively. In all risk categories, celecoxib second-line was less costly and as effective as celecoxib third-line, producing savings to the healthcare system. Although celecoxib first-line generated incremental expenditures versus celecoxib second-line, it was also more effective. The resulting cost-utility ratio for the high-risk population was Can$54,696/QALY. Based on this analytical approach, a treatment strategy where celecoxib is used before the combination of a non-selective NSAID plus a PPI possesses cost advantages for the Quebec provincial drug programme. One-way sensitivity analysis (varying GI and CV event rates, utilities, and cost) generally showed second-line treatment with celecoxib as the dominant strategy compared with third-line treatment with celecoxib.

CONCLUSION

Although effectiveness of second- and third-line celecoxib use is similar, total cost is lower for second-line. These results suggest that the use of celecoxib before the combination of a non-selective NSAID plus a PPI is relatively cost-effective in the treatment of arthritis pain and support the full benefit listing of celecoxib in Quebec's drug programme.

Primer: managing NSAID-induced ulcer complications--balancing gastrointestinal and cardiovascular risks

Ulcer complications associated with the use of NSAIDs, in high-risk patients, are often caused by a failure to identify patients' risk factors, concomitant use of aspirin or multiple NSAIDs, and underutilization of gastroprotective agents. Current data suggest that cyclo-oxygenase 2 (COX2) inhibitors and some nonselective NSAIDs increase the risk of myocardial infarction. Physicians must, therefore, take into account both the gastrointestinal and the cardiovascular risks of individual patients when prescribing NSAIDs. In patients with a low cardiovascular risk, NSAIDs can be prescribed according to the level of gastrointestinal risk. Patients with a moderate gastrointestinal risk (one or two risk factors) should receive a COX2 inhibitor or an NSAID plus a PPI or misoprostol. Patients with more than two gastrointestinal risk factors or prior ulcer complications require the combination of a COX2 inhibitor and a PPI. Patients with a high cardiovascular risk (e.g. coronary heart disease or an estimated 10-year cardiovascular risk greater than 10%) should receive prophylactic aspirin and combination therapy with a PPI or misoprostol irrespective of the presence of gastrointestinal risk factors. Naproxen is the preferred NSAID because it is not associated with excess cardiovascular risk. Patients with a high cardiovascular risk and a very high gastrointestinal risk should avoid using NSAIDs or COX2 inhibitors.

Modeling risk of gastrointestinal events among Medicaid NSAID users using propensity scores

The purpose of the study is to evaluate the gastrointestinal risk of nonsteroidal anti-inflammatory drugs compared with cyclooxygenase-2 inhibitors in a Medicaid managed care population. Medical and prescription claims were analyzed for all Medicaid-enrollees aged 18 years and older, who received a cyclooxygenase-2 or other prescription nonsteroidal anti-inflammatory drug between January 6, 2000 and January 6, 2002, and who did not use these drugs for at least 6 months prior. A logistic model was developed of the propensity for either treatment and stratified patients by quintiles of their propensity score, adjusting for demographics, indications for nonsteroidal anti-inflammatory drugs and gastrointestinal risks. The rates of gastrointestinal event (ICD-9 codes 531-534,578) among nonsteroidal anti-inflammatory drug and cyclooxygenase-2 users were compared. The model was adjusted for drug exposure which was calculated using the medication possession ratio. Of the total sample, 73% were female, 43% were Caucasian and 29% were older than 50 years. Both the direct and the propensity adjusted model, controlling for gastroprotective agents, and medication possession ratio showed significantly different rates of gastrointestinal events in nonsteroidal anti-inflammatory drug users as compared with cyclooxygenase-2 users (odds ratio = 1.874, 95% confidence interval 1.056, 3.326) and (odds ratio = 2.088, 95% confidence interval 1.061, 4.110) respectively. A significant difference in gastrointestinal event rates was found among patients in this Medicaid population on nonsteroidal anti-inflammatory drug versus cyclooxygenase-2 inhibitors, when the gastroprotective agent use and the medication possession ratio were controlled for. Misclassification bias was accounted for by adjusting for length of drug exposure.

Upper gastrointestinal symptoms and therapies in elderly out-patients, users of non-selective NSAIDs or coxibs

BACKGROUND

The association between coxib or non-steroidal anti-inflammatory drug use with gastrointestinal symptoms and drug prescriptions in ambulatory elderly patients is not well defined.

AIM

To evaluate the association between non-steroidal anti-inflammatory drug NSAID and coxib use with gastrointestinal symptoms and therapies in elderly subjects managed by their general practitioner.

MATERIALS

The study was carried out by 133 general practitioners in Italy. By using a structured interview, sex, age, physical function, current medications, new drug prescriptions and upper gastrointestinal symptoms were registered from all elderly subjects who were referred to their general practitioners during a 2-week period. The numbers of hospitalizations, gastrointestinal bleeding events and gastrointestinal diagnostic procedures occurring during the last 6-month period were recorded.

RESULTS

Included in this study were 5515 elderly subjects. The overall prevalence of drug use was 92%. Musculo-skeletal drugs were taken by 15% of patients; NSAIDs were taken by 6%, and coxibs by 3% of patients. A significantly higher prevalence of upper gastrointestinal symptoms was observed in elderly NSAID users compared with coxib users and non-users of musculo-skeletal drugs (44% vs. 33% vs. 32% respectively, P = 0.001). The prescriptions of drugs for acid-related disorders were significantly higher in patients who were concomitantly taking NSAID rather than coxibs (13% vs. 6%, P < 0.01). The prescriptions of drugs for acid-related disorders were significantly associated with the presence of upper gastrointestinal symptoms (OR = 1.7, 95% CI = 1.6-1.9), previous gastrointestinal disorders (OR = 1.1, 95% CI = 1.0-1.3) and NSAID use (OR = 1.5, 95% CI = 1.0-2.2), but no coxib use.

CONCLUSION

In this elderly population, upper gastrointestinal symptoms and prescriptions for gastroenterological drugs were higher in non-steroidal anti-inflammatory drug users than coxib users and non-users of musculo-skeletal drugs.

Is no NSAID a good NSAID? Approaches to NSAID-associated upper gastrointestinal disease

Upper gastrointestinal disease induced by use of nonsteroidal anti-inflammatory drugs (NSAIDs) remains a major problem that affects a broad segment of the population, given the frequent use of these drugs by prescription and over the counter. The emergence of the cyclooxygenase (COX)-2 selective inhibitors (coxibs) has introduced a new option that may result in less upper gastrointestinal disease. Recent large studies have demonstrated this advantage, with the caveat that concurrent use of low-dose aspirin may mitigate this benefit. Unfortunately, the relatively high cost of the coxibs makes them not cost-effective unless confined to certain higher-risk populations. Finally, even newer versions of NSAIDs, such as nitric oxide (NO)-releasing aspirin and the COX-inhibiting NO donors, are potential alternatives to traditional NSAIDs with less upper gastrointestinal toxicity.