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Gordon CJ, Fernandez T, Chen E, Basheti M, Rahimi M, Saini B. Nurses' attitudes, beliefs and knowledge of sleep health in residential aged care: An integrative literature review. J Adv Nurs 2024. [PMID: 38819604 DOI: 10.1111/jan.16249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/25/2024] [Accepted: 05/10/2024] [Indexed: 06/01/2024]
Abstract
AIM To identify, synthesize and evaluate primary research on registered nurses' (RN) knowledge, attitudes and beliefs about sleep health and sleep health management of older adults living in residential aged care. DESIGN Integrative review. DATA SOURCES Medline, Embase and CINAHL databases from inception to September 2023. REVIEW METHODS Databases were searched using a combination of key words, subject heading terms. All abstracts and full-text articles were screened by two researchers. Qualitative synthesis of the included articles was conducted. Inductive content analysis was used to identify themes and analyse data. RESULTS A total of 923 abstracts were screened resulting in a final yield of 13 articles. Three themes were identified: (i) RN experience with sleep-disturbed residents, (ii) the emotional burden of sleep disturbances on RN and, (iii) organizational barriers to promoting resident's healthy sleep. Inappropriate administration of benzodiazepines and psychotropic drugs to manage residents' sleep disturbances was a major issue and lack of resources in residential aged care to facilitate sleep. There were concerns on nursing activity that disturbed residents' sleep and striking a balance between facilitating sleep and meeting managerial expectations was challenging. CONCLUSION This review identified that nurses' decision-making has an integral role in the management of sleep health in residents in aged care. Whilst evidence-based guidelines for managing sleep in residential aged care are available, there is a lack of translation to practice. Understanding RN perspectives is critical to improving sleep health models of care in residential aged care. IMPACT This review found that RN are attuned to the implications of sleep disturbance in residential aged care but are constrained by current sleep health models of care. PATIENT OR PUBLIC CONTRIBUTION Not applicable.
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Affiliation(s)
- Christopher J Gordon
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tracee Fernandez
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Emily Chen
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Mariam Basheti
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Matthew Rahimi
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - Bandana Saini
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Handa N, Ishizaki T, Mitsutake S, Ono K, Akishita M. Safety profile of hypnotics or sedatives on community-dwelling older adults aged 75 or older in Japan: A retrospective propensity-matched cohort study. Int J Geriatr Psychiatry 2024; 39:e6085. [PMID: 38622754 DOI: 10.1002/gps.6085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE The purpose of the study is to assess if daily use of hypnotics increases mortality, aspiration pneumonia and hip fracture among relatively healthy individuals aged 75 years or older who lead independent lives in the community. METHOD AND PATIENTS Of the adults aged 75 years or older residing in Hokkaido prefecture of Japan (n = 705,538), those who did not meet several exclusion criteria were eligible for generating propensity score-matched cohorts (n = 214,723). Exclusion criteria included co-prescribed medications acting on the central nervous system, diagnoses of malignant neoplasm, dementia, depression, etc. We compared 33,095 participants who were prescribed hypnotics for daily use (hypnotic group) with a propensity score-matched cohort without a prescription (control group). Participants were followed for more than 42 months. RESULTS During the 42-month follow-up period, the incidence of the three outcome measures in the hypnotics group was significantly higher than that in the control group (aspiration pneumonia p < 0.001, hip fracture p = 0.007, and all-cause mortality p < 0.001). Sensitivity analyses utilizing inverse probability weighting demonstrated hazard ratios of 1.083 [1.023-1.146] for mortality, 1.117 [1.014-1.230] for aspiration pneumonia, and 1.720 [1.559-1.897] for hip fracture. Meanwhile, the attribute risk differences were 2.7, 1.5, and 1.0 per 1000 patient-years, respectively. CONCLUSIONS Although daily use of hypnotics increased the risk of three events, their attribute risk differences were fewer than 3.0 per 1000 patient-years. The results will help provide guidance on whether it is reasonable to prescribe hypnotics to geriatric population aged 75 or older leading independent lives in the community. CLINICAL TRIAL REGISTRATION UMIN-CTR UMIN000048398.
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Affiliation(s)
- Nobuhiro Handa
- Department of Digital Therapeutics, Juntendo University, Graduate School of Medicine, Tokyo, Japan
- Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
- Kino-Medic Clinic, Ichigao, Yokohama, Japan
- Medical Technology Innovation Center, Juntendo University, Graduate School of Medicine, Tokyo, Japan
| | | | | | - Koki Ono
- Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
- Department of Social Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Oh TK, Hwang I, Song IA. Long-term benzodiazepine usage and mortality in patients with chronic non-cancer musculoskeletal pain: A Nationwide cohort study. Pain Pract 2024; 24:409-418. [PMID: 37872848 DOI: 10.1111/papr.13312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
OBJECTIVES The impact of benzodiazepine use on mortality in patients with chronic non-cancer pain (CNCP) has not been identified. We aimed to examine the factors associated with benzodiazepine use among patients with CNCP and examine whether long-term benzodiazepine usage is associated with mortality in patients with CNCP. METHODS This study was conducted using data from the National Health Insurance Service database of South Korea. We selected 2.5% of all adult patients diagnosed with musculoskeletal diseases (MSD) in South Korea from 2010 to 2019 using a stratified random sampling technique and included them in the analysis as patients with CNCP. The risk of 10-year all-cause mortality in patients with CNCP was investigated using the 2010 cohort of patients with CNCP. RESULTS The proportion of the study population that used benzodiazepine during the 10-year study period was 2.1% (390,683/18,770,234). Multivariable logistic regression showed that old age; increased Charlson comorbidity index (CCI); opioid, gabapentin or pregabalin, paracetamol, non-steroidal anti-inflammatory drugs, and Z-drugs usage; and underlying psychiatric comorbidities were associated with increased benzodiazepine use. In addition, benzodiazepine use was associated with increased 10-year all-cause mortality (adjusted hazard ratio: 1.03, 95% confidence interval: 1.01, 1.06; p < 0.001). CONCLUSIONS Benzodiazepine was prescribed to 2.1% of the patients with CNCP in South Korea from 2010 to 2019. Old age, increased CCI, underlying psychiatric comorbidities, and use of certain drugs are associated with increased use of benzodiazepines. In addition, benzodiazepine use is associated with 10-year all-cause mortality in patients with CNCP.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Insung Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
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Bushnell GA, Rynn MA, Gerhard T, Keyes KM, Hasin DS, Cerdá M, Nyandege A, Olfson M. Drug overdose risk with benzodiazepine treatment in young adults: Comparative analysis in privately and publicly insured individuals. Addiction 2024; 119:356-368. [PMID: 37816665 PMCID: PMC10838605 DOI: 10.1111/add.16359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND AND AIMS Benzodiazepines (BZDs) carry a risk for drug overdose and are prescribed alone or simultaneously with selective-serotonin reuptake inhibitors (SSRIs) for the treatment of anxiety and depression in young adults. We aimed to measure risks of drug overdose following BZD treatment initiation, and simultaneous BZD and SSRI initiation, compared with SSRI treatment alone in young adults with depression or anxiety. DESIGN, SETTING, PARTICIPANTS The cohort study used administrative databases covering privately (MarketScan, 1/1/2009-12/31/2018) and publicly (Medicaid, 1/1/2015-12/31/2016) insured young adults (18-29 years) in the United States. Those with depression or anxiety diagnoses newly initiating BZD or SSRI treatment (without BZD or SSRI prescriptions in prior year) were included. Simultaneous "BZD + SSRI" initiation was defined as starting BZD and SSRI treatment on the same day. The cohorts included 604 664 privately insured young adults (BZD = 22%, BZD + SSRI = 10%, SSRI = 68%) and 110 493 publicly insured young adults (BZD = 23%, BZD + SSRI = 5%, SSRI = 72%). MEASUREMENTS Incident medically treated drug overdose events were identified from emergency department and inpatient encounters (ICD poisoning codes) within 6 months of treatment initiation. Crude and propensity-score adjusted cumulative incidence and hazard ratios (HR) were estimated. Sub-analyses evaluated drug overdose intent. FINDINGS Adjusted HRs of drug overdose for BZD vs. SSRI treatment was 1.36 (95% confidence interval [CI]:1.23-1.51) in privately and 1.59 (95%CI:1.37-1.83) in publicly insured young adults. The adjusted HRs of drug overdose for BZD + SSRI treatment vs. SSRI treatment were 1.99 (95%CI:1.77-2.25) in privately and 1.98 (95%CI:1.47-2.68) in publicly insured young adults. CONCLUSIONS Among young adults in the United States, initiating benzodiazepine treatment for anxiety and depression, alone or simultaneously with selective-serotonin reuptake inhibitors (SSRI), appears to have an increased risk of medically treated drug overdose compared with SSRI treatment alone. These associations were observed in publicly and privately insured individuals.
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Affiliation(s)
- Greta A Bushnell
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers University School of Public Health, Piscataway, NJ, USA
| | - Moira A Rynn
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Tobias Gerhard
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ, USA
| | - Katherine M Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Deborah S Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Abner Nyandege
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
| | - Mark Olfson
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
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El-Solh AA, Lawson Y, Wilding GE. Association Between Hypnotic Use and All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease and Insomnia. Int J Chron Obstruct Pulmon Dis 2023; 18:2393-2404. [PMID: 37942297 PMCID: PMC10629458 DOI: 10.2147/copd.s430609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023] Open
Abstract
Purpose Hypnotics are commonly prescribed in patients with COPD to manage insomnia. Given the considerable risks associated with these drugs, the aim of the study was to evaluate the risk of all-cause mortality associated with hypnotics in a cohort of veterans with COPD presenting with insomnia. Methods We conducted a retrospective cohort study that used Veterans Health Administration Corporate Data Warehouse with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2010 through 2019. The primary outcome was all-cause mortality. Analyses were conducted using propensity score 1:1 matching to balance baseline characteristics. Results Of the 5759 veterans with COPD (mean [SD] age, 71.7 [11.2]; 92% men), 3585 newly initiated hypnotic agents during the study period. During a mean follow-up of 7.4 (SD, 2.7) years, a total of 2301 deaths occurred, with 65.2 and 48.7 total deaths per 1000 person-years among hypnotic users and nonusers, respectively. After propensity matching, hypnotic use was associated with a 22% increased risk of mortality compared with hypnotic nonusers (hazard ratio [HR] 1.22; 95% confidence interval [CI],1.11-1.35). The benzodiazepine receptor agonists (BZRAs) group experienced a higher incidence rate of all-cause mortality compared to hypnotic nonusers (Incidence rate ratio [IRR] 1.27; 95% CI, 1.14-1.43). Conversely, the mortality rate of non-BZRA hypnotics decreased after the first 2 years and was not significantly different for hypnotic nonusers (IRR 1.04; 95% CI, 0.82-1.11). Conclusion Among patients with COPD and insomnia, treatment with hypnotics was associated with a higher risk of all-cause mortality. The association was observed in patients prescribed BZRAs. The risk of mortality for non-BZRAs moderated after the first 2 years, indicating a class effect.
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Affiliation(s)
- Ali A El-Solh
- Research Department, VA Western New York Healthcare System, Buffalo, NY, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine; Jacobs School of Medicine, Buffalo, NY, USA
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions; University at Buffalo, Buffalo, NY, USA
| | - Yolanda Lawson
- Research Department, VA Western New York Healthcare System, Buffalo, NY, USA
| | - Gregory E Wilding
- Department of Biostatistics, School of Public Health and Health Professions; University at Buffalo, Buffalo, NY, USA
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Vilalta-Lacarra A, Vilalta-Franch J, Serrano-Sarbosa D, Martí-Lluch R, Marrugat J, Garre-Olmo J. Association of depression phenotypes and antidepressant treatment with mortality due to cancer and other causes: a community-based cohort study. Front Psychol 2023; 14:1192462. [PMID: 37711322 PMCID: PMC10497951 DOI: 10.3389/fpsyg.2023.1192462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/31/2023] [Indexed: 09/16/2023] Open
Abstract
Objective This study aimed to assess the association of somatic depressive symptoms (SDS), cognitive/emotional depressive symptoms (C-EDS), and antidepressant treatment on mortality due to cancer and other causes in a community cohort. Methods A community-based sample recruited in 1995, 2000, and 2005 aged between 35 and 75 years was examined in two waves and followed for a median of 6.7 years. SDS and C-EDS phenotypes were assessed using the Patient Health Questionnaire-9. Medication used by participants was collected. Deaths and their causes were registered during follow-up. Cox proportional hazard models stratified by sex were performed to determine the association between depressive phenotypes and mortality. Results The cohort consisted of 5,646 individuals (53.9% women) with a mean age of 64 years (SD = 11.89). During the follow-up, 392 deaths were recorded, of which 27.8% were due to cancer. C-EDS phenotype was associated with an increased risk of cancer mortality in both men (HR = 2.23; 95% CI = 1.11-4.44) and women (HR = 3.69; 95% CI = 1.69-8.09), and SDS was significantly associated with non-cancer mortality in men (HR = 2.16; 95 CI % = 1.46-3.18). Selective serotonin reuptake inhibitors (SSRIs) were significantly associated with both cancer (HR = 2.78; 95% CI = 1.10-6.98) and non-cancer mortality (HR = 2.94; 95% CI = 1.76-4.90) only in the male population. Conclusion C-EDS phenotype was related to an increased risk of cancer mortality at 6 years. In addition, the use of SSRIs in the male population was associated with cancer and all-cause mortality.
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Affiliation(s)
| | | | - Domènec Serrano-Sarbosa
- Girona Biomedical Research Institute (IDIBGI), Girona, Spain
- Institut d'Assistencia Sanitaria, Girona, Spain
- Department of Medical Sciences, University of Girona, Girona, Spain
| | - Ruth Martí-Lluch
- Girona Biomedical Research Institute (IDIBGI), Girona, Spain
- Vascular Health Research Group (ISV-Girona), Foundation University Institute for Primary Health Care Research Jordi Gol i Gurina, Girona, Spain
| | - Jaume Marrugat
- IMIM-Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
- CIBERCV de Investigación en Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Garre-Olmo
- Girona Biomedical Research Institute (IDIBGI), Girona, Spain
- Department of Nursing, University of Girona, Girona, Spain
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Yoshioka R, Yamamoto S, Nakatani E. Effectiveness of suvorexant versus benzodiazepine receptor agonist sleep drugs in reducing the risk of hip fracture: Findings from a regional population-based cohort study. PLoS One 2023; 18:e0284726. [PMID: 37093840 PMCID: PMC10124872 DOI: 10.1371/journal.pone.0284726] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/05/2023] [Indexed: 04/25/2023] Open
Abstract
Sleep drugs are often necessary to treat insomnia in older patients. Benzodiazepine receptor agonists (BZRAs) are primarily used for insomnia in these patients, but there are concerns regarding their association with delirium and bone fractures. Among sleep drugs, orexin receptor antagonists such as suvorexant have a lower risk of delirium than BZRAs, but their effectiveness in preventing hip fractures is unknown. Hip fracture is a life-threatening trauma in advanced-age patients and a social problem. Therefore, we investigated the relationship between suvorexant and hip fracture. The Shizuoka Kokuho Database was used to compare the time to hip fracture in patients who had been newly taking suvorexant and other sleep drugs such as benzodiazepines since November 2014. A proportional hazards model for hip fracture as an outcome was used to estimate the hazard ratio. Propensity scores were estimated using a logistic regression model, and the confounding factors were age, sex, several comorbidities, and each oral medication. The suvorexant group comprised 6860 patients (110 with hip fracture), and the BZRA group (benzodiazepines and Z-drugs) comprised 50,203 patients (1487 with hip fracture). In the matched cohort (6855:6855 patients), 259 and 249 patients in the suvorexant and BZRA group developed hip fractures during the observational period, respectively. The hazard ratio of the suvorexant group compared with the BZRA group was 1.48 (95% confidence interval, 1.20-1.82). In the subgroup analysis, patients in the suvorexant group had a higher risk of hip fracture if they were aged >75 years, had no diabetes, had no neurological disease, had no renal failure, had liver disease, had hypertension, were not taking alpha 1 blockers, and were not taking oral steroids. Among people in the Japanese regional population who use sleep drugs, patients taking suvorexant can be at higher risk of hip fracture than patients taking BZRAs.
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Affiliation(s)
- Ryozo Yoshioka
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
- Department of Emergency Medicine, Shizuoka General Hospital, Aoi-ku, Shizuoka, Japan
| | - Seiichiro Yamamoto
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Eiji Nakatani
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
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Secemsky EA, Barrette E, Bockstedt L, Yeh RW. Assessment of the Social Security Administration Death Master File for Comparative Analysis Studies of Peripheral Vascular Devices. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:55-59. [PMID: 35680547 PMCID: PMC9722978 DOI: 10.1016/j.jval.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/04/2022] [Accepted: 05/01/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The objective of this study was to assess the reliability the Social Security Administration Death Master File (SSADMF) for evaluating mortality in comparative peripheral vascular device studies. METHODS We leveraged 2 versions of an administrative claims data set that were identical except for the source of mortality data. The SSADMF was the primary source of mortality records in one version. The SSADMF was combined with mortality from Medicare beneficiary records in the other. Our study was set in the context of a comparative effectiveness analysis of recent Food and Drug Administration interest involving peripheral paclitaxel-coated devices. Mortality of patients with Medicare Advantage insurance coverage from 2015 to 2018 who underwent femoropopliteal artery revascularization with a drug-coated device (DCD) or non-DCD was assessed through 2019. Covariate differences between treatment groups were adjusted by inverse propensity treatment weighting. The hazard ratio of DCD to non-DCD mortality was estimated using Cox regression. RESULTS The cumulative incidences of mortality differed substantially between versions of the data. Nevertheless, we could not reject the null hypothesis that the hazard ratios of the SSADMF (1.05; 95% confidence interval 0.95-1.17) and the Master Beneficiary Summary File/SSADMF (1.03; 95% confidence interval 0.96-1.11) were the same (P = .63). CONCLUSIONS The SSADMF is a common source of mortality records in the United States that can be linked to real-world data sources but is known to underreport mortality rates. We find that the SSADMF provides a reliable source of all-cause mortality for a comparative study assessing the safety of peripheral vascular devices.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | | | | | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Liu S, Soedamah-Muthu SS, van Meerten SC, Kromhout D, Geleijnse JM, Giltay EJ. Use of benzodiazepine and Z-drugs and mortality in older adults after myocardial infarction. Int J Geriatr Psychiatry 2023; 38:e5861. [PMID: 36514248 PMCID: PMC10107716 DOI: 10.1002/gps.5861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The adverse cardiovascular effects of benzodiazepines and Z-drugs (jointly referred as BZDRs) have been of concern. Yet, little is known about the use of BZDRs in relation to mortality risk among older adults with myocardial infarction history (post-MI). METHODS This study is a secondary analysis of the Alpha Omega Cohort study, comprising post-MI patients aged 40-60 years. Self-reported information on the use of BZDRs, including types and dose, was collected at baseline. Four categories of mortality were examined, namely all-cause mortality, cardiovascular (CVD) mortality, cancer mortality, and non-CVD/non-cancer mortality. Associations between BZDRs use, by types and doses, and mortality were estimated with Cox regression models, adjusted for demographic and classic cardiovascular risk factors. RESULTS A total of 433 (8.9%) out of 4837 (21.8% females) patients reported BZDRs use at baseline. During a median follow-up of 12.4 years, 2287 deaths were documented, of which 825 (36.1%) were due to CVD. BZDRs use was related to a statistically significantly higher risk of all-cause and CVD mortality; adjusted hazard ratios [95% CI] were (1.31 [1.41, 1.52]) and (1.43 [1.14, 1.81]), respectively. These relationships were dose-dependent-patients using BZDRs on an as-needed basis had similar risks compared to the non-uses, whereas patients with a daily use schedule and increasing doses had higher risks (p-value for trend: <0.001). CONCLUSION BZDRs use was independently associated with a higher risk of all-cause and cardiovascular mortality in older post-MI patients, and there was evidence for a dose-dependent relationship. CLINICAL TRIAL REGISTRATION NCT00127452 (www. CLINICALTRIALS gov).
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Affiliation(s)
- Shengxin Liu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Sabita S Soedamah-Muthu
- Center of Research on Psychological Disorders and Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Institute for Food, Nutrition and Health (IFNH), University of Reading, Reading, UK
| | - Seia C van Meerten
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
| | - Daan Kromhout
- Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Johanna M Geleijnse
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Erik J Giltay
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
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Hu X, Jong GP, Wang L, Lin MC, Gong SQ, Zhang XH, Lin JJ, Adeniran E, Liu YL, Chen HY, Yang B. Hypnotics Use Is Associated with Elevated Incident Atrial Fibrillation: A Propensity-Score Matched Analysis of Cohort Study. J Pers Med 2022; 12:jpm12101645. [PMID: 36294784 PMCID: PMC9605069 DOI: 10.3390/jpm12101645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
We aimed to investigate the association between either or both of benzodiazepines (BZDs) and non-BZDs and the incidence of atrial fibrillation (AF) in the Taiwan National Health Insurance Database. The participants with at least two prescriptions of BZDs and/or non-BZDs were identified as hypnotics users, whereas those without any prescription of hypnotics were non-hypnotics users. The hypnotics and non-hypnotics cohorts were 1:1 matched on their propensity scores. A total of 109,704 AF-free individuals were included; 610 AF cases occurred in the 54,852 hypnotics users and 166 in the 54,852 non-hypnotics users during the 602,470 person-years of follow-up, with a higher risk of new-onset AF in the users than the non-users (hazard ratio (HR): 3.61, 95% confidence interval [CI]: 3.04−4.28). The users at the highest tertiles of the estimated defined daily doses per one year (DDD) had a greater risk for AF than the non-users, with the risk increasing by 7.13-fold (95% CI: 5.86−8.67) for >0.74-DDD BZDs, 10.68-fold (95% CI: 6.13−18.62) for >4.72-DDD non-BZDs, and 3.26-fold (95% CI: 2.38−4.47) for > 1.65-DDD combinations of BZDs with non-BZDs, respectively. In conclusion, hypnotics use was associated with elevated incidence of AF in the Taiwanese population, which highlighted that the high-dose usage of hypnotics needs more caution in clinical cardiological practice.
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Affiliation(s)
- Xiang Hu
- Department of Endocrine and Metabolic Diseases, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- School of Public Health and Management, Wenzhou Medical University, Wenzhou 325035, China
| | - Gwo-Ping Jong
- Division of Cardiology, Department of Medicine, Chung Shan Medical University Hospital, Chung Shan Medical University, Taichung 402, Taiwan
| | - Liang Wang
- Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, TX 76798, USA
| | - Mei-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan
- College of Medicine, China Medical University, Taichung 404, Taiwan
| | - Shao-Qing Gong
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an 710049, China
| | - Xue-Hong Zhang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Jiun-Jie Lin
- Department of Pharmacy, Feng-Yuan Hospital, Ministry of Health Welfare, Taichung 420, Taiwan
| | - Esther Adeniran
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - Yan-Long Liu
- School of Public Health and Management, Wenzhou Medical University, Wenzhou 325035, China
| | - Hung-Yi Chen
- Department of Pharmacy, China Medical University, Taichung 404, Taiwan
- Department of Pharmacy, China Medical University Beigang Hospital, Yunlin 651, Taiwan
- Correspondence: (H.-Y.C.); (B.Y.); Tel./Fax: +86-577-86687632 (B.Y.)
| | - Bo Yang
- School of Public Health and Management, Wenzhou Medical University, Wenzhou 325035, China
- Department of Pharmacy, China Medical University, Taichung 404, Taiwan
- Correspondence: (H.-Y.C.); (B.Y.); Tel./Fax: +86-577-86687632 (B.Y.)
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11
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Wang SV, Sreedhara SK, Schneeweiss S. Reproducibility of real-world evidence studies using clinical practice data to inform regulatory and coverage decisions. Nat Commun 2022; 13:5126. [PMID: 36045130 PMCID: PMC9430007 DOI: 10.1038/s41467-022-32310-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 07/26/2022] [Indexed: 11/26/2022] Open
Abstract
Studies that generate real-world evidence on the effects of medical products through analysis of digital data collected in clinical practice provide key insights for regulators, payers, and other healthcare decision-makers. Ensuring reproducibility of such findings is fundamental to effective evidence-based decision-making. We reproduce results for 150 studies published in peer-reviewed journals using the same healthcare databases as original investigators and evaluate the completeness of reporting for 250. Original and reproduction effect sizes were positively correlated (Pearson’s correlation = 0.85), a strong relationship with some room for improvement. The median and interquartile range for the relative magnitude of effect (e.g., hazard ratiooriginal/hazard ratioreproduction) is 1.0 [0.9, 1.1], range [0.3, 2.1]. While the majority of results are closely reproduced, a subset are not. The latter can be explained by incomplete reporting and updated data. Greater methodological transparency aligned with new guidance may further improve reproducibility and validity assessment, thus facilitating evidence-based decision-making. Study registration number: EUPAS19636. Analyses of real-world evidence from digital clinical practice data provide important insights for healthcare decision makers. Here, authors test reproducibility of 150 peer-reviewed studies, reporting strong reproducibility, which could be further improved through more complete reporting in future original studies
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Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | | | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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Fujii E, Kato Y, Suzuki S, Uejima T, Arita T, Yagi N, Kishi M, Kano H, Matsuno S, Otsuka T, Oikawa Y, Matsuhama M, Iida M, Inoue T, Yajima J, Yamashita T. Relationship between the prescription of sleep inducers and prognosis in patients with cardiovascular diseases. Eur J Prev Cardiol 2022; 29:e347-e349. [PMID: 35801566 DOI: 10.1093/eurjpc/zwac137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/15/2022] [Accepted: 07/02/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Emi Fujii
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Yuko Kato
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Tokuhisa Uejima
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Takuto Arita
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Naoharu Yagi
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Mikio Kishi
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Hiroto Kano
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Shunsuke Matsuno
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Yuji Oikawa
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Minoru Matsuhama
- Department of Cardiovascular Surgery, the Cardiovascular Institute, Tokyo, Japan
| | - Mitsuru Iida
- Department of Cardiovascular Surgery, the Cardiovascular Institute, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Cardiovascular Surgery, the Cardiovascular Institute, Tokyo, Japan
| | - Junji Yajima
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
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13
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Hoertel N, Sánchez-Rico M, Gulbins E, Kornhuber J, Vernet R, Beeker N, Neuraz A, Blanco C, Olfson M, Airagnes G, Lemogne C, Alvarado JM, Arnaout M, Cougoule C, Meneton P, Limosin F. Association between benzodiazepine receptor agonist use and mortality in patients hospitalised for COVID-19: a multicentre observational study. Epidemiol Psychiatr Sci 2022; 31:e18. [PMID: 35352674 PMCID: PMC8967698 DOI: 10.1017/s2045796021000743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 11/24/2021] [Accepted: 12/04/2021] [Indexed: 11/18/2022] Open
Abstract
AIMS To examine the association between benzodiazepine receptor agonist (BZRA) use and mortality in patients hospitalised for coronavirus disease 2019 (COVID-19). METHODS A multicentre observational study was performed at Greater Paris University hospitals. The sample involved 14 381 patients hospitalised for COVID-19. A total of 686 (4.8%) inpatients received a BZRA at hospital admission at a mean daily diazepam-equivalent dose of 19.7 mg (standard deviation (s.d.) = 25.4). The study baseline was the date of admission, and the primary endpoint was death. We compared this endpoint between patients who received BZRAs and those who did not in time-to-event analyses adjusted for sociodemographic characteristics, medical comorbidities and other medications. The primary analysis was a Cox regression model with inverse probability weighting (IPW). RESULTS Over a mean follow-up of 14.5 days (s.d. = 18.1), the primary endpoint occurred in 186 patients (27.1%) who received BZRAs and in 1134 patients (8.3%) who did not. There was a significant association between BZRA use and increased mortality both in the crude analysis (hazard ratio (HR) = 3.20; 95% confidence interval (CI) = 2.74-3.74; p < 0.01) and in the IPW analysis (HR = 1.61; 95% CI = 1.31-1.98, p < 0.01), with a significant dose-dependent relationship (HR = 1.55; 95% CI = 1.08-2.22; p = 0.02). This association remained significant in sensitivity analyses. Exploratory analyses indicate that most BZRAs may be associated with an increased mortality among patients hospitalised for COVID-19, except for diazepam, which may be associated with a reduced mortality compared with any other BZRA treatment. CONCLUSIONS BZRA use may be associated with an increased mortality among patients hospitalised for COVID-19, suggesting the potential benefit of decreasing dose or tapering off gradually these medications when possible.
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Affiliation(s)
- N. Hoertel
- Département de Psychiatrie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, DMU Psychiatrie et Addictologie, Issy-les-Moulineaux, France
- Université de Paris, Paris, France
- INSERM, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Paris, France
| | - M. Sánchez-Rico
- Département de Psychiatrie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, DMU Psychiatrie et Addictologie, Issy-les-Moulineaux, France
- Department of Psychobiology & Behavioural Sciences Methods, Faculty of Psychology, Universidad Complutense de Madrid, Campus de Somosaguas, Pozuelo de Alarcon, Spain
| | - E. Gulbins
- Institute for Molecular Biology, University Medicine Essen, University of Duisburg-Essen, Essen, Germany
| | - J. Kornhuber
- Department of Psychiatry and Psychotherapy, University Hospital Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany
| | - R. Vernet
- Medical Informatics, Biostatistics and Public Health Department, AP-HP, Centre-Université de Paris, Hôpital Européen Georges Pompidou, F-75015Paris, France
| | - N. Beeker
- Assistance Publique-Hôpitaux de Paris (AP-HP), Unité de Recherche Clinique, Hôpital Cochin, Paris, France
| | - A. Neuraz
- INSERM, UMR_S 1138, Cordeliers Research Center, Université de Paris, Paris, France
- Department of Medical Informatics, AP-HP, Centre-Université de Paris, Necker-Enfants Malades Hospital, Paris, France
| | - C. Blanco
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse, 6001 Executive Boulevard, Bethesda, MD20852, USA
| | - M. Olfson
- Department of Psychiatry, Columbia University/New York State Psychiatric Institute, 1051 Riverside Drive, Unit 69, New York, NY10032, USA
| | - G. Airagnes
- Département de Psychiatrie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, DMU Psychiatrie et Addictologie, Issy-les-Moulineaux, France
- Université de Paris, Paris, France
- INSERM, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Paris, France
- INSERM, UMS 011, Population-based Epidemiologic Cohorts, Villejuif, France
| | - C. Lemogne
- Université de Paris, Paris, France
- INSERM, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Paris, France
- AP-HP, Hôpital Hôtel-Dieu, DMU Psychiatrie et Addictologie, Service de Psychiatrie de l'adulte, Paris, France
| | - J. M. Alvarado
- Department of Psychobiology & Behavioural Sciences Methods, Faculty of Psychology, Universidad Complutense de Madrid, Campus de Somosaguas, Pozuelo de Alarcon, Spain
| | - M. Arnaout
- Anesthesia and Intensive Care Department, Hôpitaux Universitaires Paris Île-de-France Ouest, Boulogne-Billancourt, France
| | - C. Cougoule
- Institut de Pharmacologie et de Biologie Structurale, IPBS, Université de Toulouse, Toulouse, France
| | - P. Meneton
- INSERM U1142 LIMICS, UMRS 1142, Sorbonne Universities, UPMC University of Paris 06, University of Paris 13, Paris, France
| | - F. Limosin
- Département de Psychiatrie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, DMU Psychiatrie et Addictologie, Issy-les-Moulineaux, France
- Université de Paris, Paris, France
- INSERM, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Paris, France
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Yeh JJ, Lai MC, Yang YC, Hsu CY, Kao CH. Relationships Between Bronchodilators, Steroids, Antiarrhythmic Drugs, Antidepressants, and Benzodiazepines and Heart Disease and Ischemic Stroke in Patients With Predominant Bronchiectasis and Asthma. Front Cardiovasc Med 2022; 9:797623. [PMID: 35252385 PMCID: PMC8893278 DOI: 10.3389/fcvm.2022.797623] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/17/2022] [Indexed: 01/09/2023] Open
Abstract
ObjectiveWe investigated the effects of medication on heart disease and ischemic stroke (HDS) risk in patients with predominant bronchiectasis-asthma combination (BCAS).MethodsBCAS and non-BCAS cohorts (N = 588 and 1,118, respectively) were retrospectively enrolled. The cumulative incidence of HDS was analyzed using Cox proportional regression; propensity scores were estimated using non-parsimonious multivariable logistic regression. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for HDS were calculated, adjusting for sex, age, comorbidities, and medication {long- and short-acting β2 agonists and muscarinic antagonists (LABAs/SABAs and LAMAs/SAMAs), steroids [inhaled corticosteroid steroids (ICSs), oral steroids (OSs)], antiarrhythmics, antidepressants (fluoxetine), benzodiazepines (alprazolam, fludiazepam), statins and antihypertensive drugs (diuretics, cardioselective beta blockers, calcium channel blockers (CCBs) and angiotensin converting enzyme inhibitors (ACEi), angiotensin II blockers)}.ResultsCompared with the non-BCAS cohort, the BCAS cohort taking LABAs, SABAs, SAMAs, ICSs, OSs, antiarrhythmics, and alprazolam had an elevated HDS risk [aHRs (95% CIs): 2.36 (1.25–4.33), 2.65 (1.87–3.75), 2.66 (1.74–4.05), 2.53 (1.61–3.99), 1.76 (1.43–2.18), 9.88 (3.27–30.5), and 1.73 (1.15–2.58), respectively except fludiazepam 1.33 (0.73–2.40)]. The aHRs (95% CIs) for LABAs ≤ 30 days, DDDs <415, ICSs ≤ 30 days were 1.10 (0.38–3.15), 2.95 (0.22–38.8), 1.45 (0.76–2.77). The aHRs (95% CIs) for current and recent alprazolam were 1.78 (1.09–2.93) and 777.8 (1.34–451590.0); for current and past fludiazepam were 1.39 (0.75–2.59) and 1.29 (0.42–4.01) and for past alprazolam was 1.57 (0.55–4.46); respectively. The aHRs (95% CIs) for alprazolam >30 DDDs, fludiazepam >20 DDDs, ICSs ≦415 DDDs, and OSs DDDs ≦15 were 1.60 (0.78–3.29), 2.43 (0.90–6.55), 5.02 (1.76–14.3), and 2.28 (1.43–3.62), respectively.ConclusionThe bronchodilators, steroids, and antiarrhythmics were associated with higher risk of HDS, even low dose use of steroids. However, the current use of LABAs/ICSs were not associated with HDS. Benzodiazepines were relatively safe, except for current or recent alprazolam use. Notably, taking confounders into account is crucial in observational studies.
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Affiliation(s)
- Jun-Jun Yeh
- Department of Family Medicine, Chest Medicine, Geriatric Medicine and Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Mei-Chu Lai
- Department of Laboratory Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Yu-Cih Yang
- College of Medicine, China Medical University, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Chung-Y. Hsu
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
- *Correspondence: Chia-Hung Kao ;
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15
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Association Between Benzodiazepine and Opioid Prescription and Mortality Among Patients in a Large Healthcare System. J Addict Med 2022; 16:65-71. [PMID: 35120065 PMCID: PMC8817063 DOI: 10.1097/adm.0000000000000828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Coprescription of opioids and benzodiazepines (BDZ) is associated with adverse outcomes, including greater healthcare utilization and overdose risk. This study aims to examine opioid and BDZ coprescription, dosing, and mortality among patients with and without opioid use disorder (OUD) in a large healthcare system. METHODS Using data from the California state Prescription Drug Monitoring Program during 2010 to 2014 linked with a large healthcare system electronic health record database and mortality records from the Centers for Disease Control National Death Index, this study examined 5202 patients (1978 with OUD, 3224 controls). Multiple logistic regression analyses were conducted to examine relationships between most recent BDZ and opioid prescription, and their interaction with respect to mortality. RESULTS About 10.5% of the sample died on or before December 31, 2014. About 17.7% were prescribed BDZ during the final month of observation. Individuals with OUD were prescribed higher average BDZ and opioid doses than those without OUD. After adjusting for covariates, increased prescribed doses of BDZ (odds ratio [OR]=1.34, 95%CI: 1.15-1.55 per 10 mg/d increment) and opioids (OR = 1.04, 95%CI: 1.02-1.05 per 10 mg/d increment) were positively associated with mortality. Non-OUD patients who received both BDZ and opioid prescriptions had a higher mortality than those who received only BDZ or opioids (The ratio of odds ratio (ROR) = 3.83, 95%CI: 1.78-8.21). CONCLUSIONS Study findings highlight significant mortality associated with the coprescription of opioids and BDZ in a general healthcare setting. Further research is needed to elucidate factors associated with mortality among non-OUD patients who are co-prescribed opioids and BDZ.
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Xu KY, Borodovsky JT, Presnall N, Mintz CM, Hartz SM, Bierut LJ, Grucza RA. Association Between Benzodiazepine or Z-Drug Prescriptions and Drug-Related Poisonings Among Patients Receiving Buprenorphine Maintenance: A Case-Crossover Analysis. Am J Psychiatry 2021; 178:651-659. [PMID: 33653119 PMCID: PMC8286284 DOI: 10.1176/appi.ajp.2020.20081174] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Persons with opioid use disorder who take benzodiazepines are at high risk for overdose. The objective of this study was to evaluate the association of benzodiazepine and Z-drug use with drug-related poisonings among patients receiving buprenorphine maintenance treatment. METHODS A case-crossover study design was used to analyze prescription claims among persons ages 12-64 with opioid use disorder who had buprenorphine prescriptions and had claims data in the IBM MarketScan databases (2006-2016), encompassing 14,213,075 person-days of observation time for 23,036 individuals who experienced drug-related poisoning. The exposures were buprenorphine prescriptions and benzodiazepine or Z-drug prescriptions, standardized as daily diazepam-equivalent milligram doses and separated by pharmacologic properties (short-acting or long-acting benzodiazepines, Z-drugs). The outcome of interest was nonfatal drug-related poisoning. Conditional logistic regression was used to evaluate variation in benzodiazepine or Z-drug and buprenorphine use between poisoning and nonpoisoning days. RESULTS Buprenorphine treatment days were associated with a nearly 40% reduction in the risk of poisoning events (odds ratio=0.63, 95% CI=0.60, 0.66) compared with nontreatment days, whereas benzodiazepine or Z-drug treatment days were associated with an 88% increase in the risk of such events (95% CI=1.78, 1.98). In stratified analyses by dose, we observed a 78% (95% CI=1.67, 1.88) and 122% (95% CI=2.03, 2.43) increase in poisonings associated with low-dose and high-dose benzodiazepine or Z-drug treatment days, respectively. High-dose, but not low-dose, benzodiazepine or Z-drug treatment was associated with increased poisonings in combination with buprenorphine cotreatment (odds ratio=1.64, 95% CI=1.39, 1.93), but this was lower than the odds risk associated with benzodiazepine or Z-drug treatment in the absence of buprenorphine (low-dose: odds ratio=1.69, 95% CI=1.60, 1.79; high-dose: odds ratio=2.23, 95% CI=2.04, 2.45). CONCLUSIONS Increased risk of nonfatal drug-related poisoning is associated with benzodiazepine or Z-drug treatment in patients with opioid use disorder, but this risk is partially mitigated by buprenorphine treatment. Dose reduction of benzodiazepines or Z-drugs while maintaining buprenorphine treatment may provide the advantage of lowering drug-related poisoning risk.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Jacob T Borodovsky
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Ned Presnall
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Carrie M Mintz
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Sarah M Hartz
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Laura J Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
- Alvin J Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, MO
| | - Richard A Grucza
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO
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Song IA, Park HY, Oh TK. Sleep Disorder and Long-Term Mortality Among Sepsis Survivors: A Nationwide Cohort Study in South Korea. Nat Sci Sleep 2021; 13:979-988. [PMID: 34234601 PMCID: PMC8254539 DOI: 10.2147/nss.s319769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We aimed to investigate the association of sleep disorder diagnosis among sepsis survivors with 5-year all-cause mortality. METHODS Using the National Health Insurance Service (NHIS) database of South Korea, we included adult sepsis survivors who were primarily diagnosed with sepsis between 2011 and 2014 and survived for more than one year after diagnosis. The diagnosis of sleep disorders was evaluated using the International Classification of Diseases, 10th revision codes of G47* in the NHIS database. RESULTS In total, 45,826 survivors of sepsis were included in this analysis. Among the sepsis survivors, 2935 (6.4%) were newly diagnosed with a sleep disorder within 1 year after the date of sepsis diagnosis, while 7938 (17.3%) were already diagnosed with sleep disorder before the date of sepsis diagnosis. In the multivariable Cox regression, the risk of 5-year all-cause mortality in the pre- and post-sepsis sleep disorder groups was 1.19-fold (hazard ratio: 1.19, 95% confidence interval: 1.14-1.24; P<0.001) and 1.79-fold (hazard ratio: 1.79, 95% confidence interval: 1.70-1.89; P<0.001) higher than that of the control group. CONCLUSION A 6.4% of sepsis survivors in South Korea were newly diagnosed with a sleep disorder within 1 year of sepsis diagnosis. Although both pre- and post-sepsis sleep disorders were associated with a higher 5-year all-cause mortality rate, the risk of the 5-year all-cause mortality in the post-sepsis sleep disorder group was higher than that in the pre-sepsis sleep disorder group.
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Affiliation(s)
- In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hye Yoon Park
- Department of Psychiatry, Seoul National University Hospital, Seoul, South Korea
- Department of Psychiatry, College of Medicine, Seoul National University, Seoul, South Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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18
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Dong M, E JY, Zhang L, Teng W, Tian L. Non-ketotic Hyperglycemia Chorea-Ballismus and Intracerebral Hemorrhage: A Case Report and Literature Review. Front Neurosci 2021; 15:690761. [PMID: 34248493 PMCID: PMC8260933 DOI: 10.3389/fnins.2021.690761] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/11/2021] [Indexed: 11/13/2022] Open
Abstract
Non-ketotic hyperglycemia chorea-ballismus (NKH-CB) is a rare metabolical syndrome secondary to the hyperglycemic condition, which is characterized by a triad of acute or subacute hemichorea-hemiballismus, hyperglycemic state, and unique abnormalities limited to the striatum on neuroimaging. Several related case studies on this disorder have been reported previously, but NKH-CB had never been associated with intracerebral hemorrhage (ICH). Herein, we report an uncommon case of NKH-CB and ICH that occurred simultaneously in one patient, which provides a challenge for clinicians in making a correct diagnosis. An 88-year-old woman with a long-term history of poor-controlled type 2 diabetes mellitus and hypertension, who presented with a sudden-onset headache, restlessness, severe bilateral choreiform and ballistic movements, elevated levels of glucose and osmolality in the serum, an increased white blood cell count, and two-type hyperdense signs on CT imaging, was finally diagnosed with NKH-CB and ICH. Despite administrated active treatments, the patient's clinical status did not improve and ultimately passed away. This case is reported to remind clinicians to consider the possibility of NKH-CB when patients present sudden-onset choreiform and ballistic movements. It is also the first entity with two-type hyperdense signs on CT imaging simultaneously, which helps us distinguish NKH-CB from ICH more intuitively.
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Affiliation(s)
- Mingming Dong
- Department of Neurology, The Fourth People's Hospital of Shenyang, Shenyang, China.,Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Jian-Yu E
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Liyang Zhang
- Department of Neurology, The Fourth People's Hospital of Shenyang, Shenyang, China
| | - Weiyu Teng
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Li Tian
- Department of Geriatrics, Shengjing Hospital of China Medical University, Shenyang, China
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19
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Oh TK, Park HY, Song IA. Benzodiazepine Use and Long-Term Mortality in South Korean Adult Population: A Cohort Study. Yonsei Med J 2021; 62:528-534. [PMID: 34027640 PMCID: PMC8149930 DOI: 10.3349/ymj.2021.62.6.528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Studies have reported mixed results on the association between benzodiazepine use and mortality. Here, we investigated whether benzodiazepine use is associated with a higher risk of 5-year all-cause mortality, and examined the association between benzodiazepine use and 5-year disease-specific mortality. MATERIALS AND METHODS In this population-based cohort study, a nationally representative sample cohort in South Korea was examined. In 2010, benzodiazepine users were defined as individuals prescribed benzodiazepine continuously over 30 days for regular administration, and all other subjects were included in the control group. The primary endpoint was 5-year all-cause mortality, evaluated from 2011 to 2015. Propensity score (PS) matching and time-dependent Cox regression were performed for statistical analysis, which included benzodiazepine use during 2011-2015 as a time-dependent variable. RESULTS A total of 822414 adult individuals were included in the final analysis, and the all-cause 5-year mortality was recorded in 20991 individuals (2.7%). The benzodiazepine group included 30837 patients and the control group comprised 791377 patients. After PS matching, 61672 individuals (30836 in each group) were included in the final analysis. After PS matching, the 5-year all-cause mortality in the benzodiazepine group was 10.0% (3082/30836), whereas that in the control group was 9.4% (2893/30836). In time-dependent Cox regression analysis of the PS-matched cohort, the benzodiazepine group showed 1.15-fold higher 5-year all-cause mortality (hazard ratio: 1.15, 95% confidence interval: 1.09-1.22; p<0.001) compared to the control group. CONCLUSION Benzodiazepine use was associated with increased 5-year all-cause mortality in the South Korean adult population. Further studies are needed to confirm these findings.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Youn Park
- Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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20
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Opioid prescribing and health outcomes in opioid-naive patients: Analysis of a statewide health information exchange. J Am Pharm Assoc (2003) 2021; 61:623-631.e3. [PMID: 34045156 DOI: 10.1016/j.japh.2021.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Widespread use of prescription opioids is associated with adverse outcomes. OBJECTIVE To identify factors associated with adverse health outcomes and health care use using a statewide health information exchange. METHODS This is a retrospective cohort study using the Indiana Network for Patient Care. Adult opioid-naive patients who received an opioid prescription between January 2012 and December 2017 were included. The outcomes included (1) a composite outcome of any combination of opioid abuse, dependence, or overdose, (2) all-cause mortality, and (3) health care use. Independent variables included opioid dosage, dispensed amount, days supply, concurrent use of short-acting (SA) and long-acting (LA) opioids, and concurrent use with benzodiazepine or gabapentinoids. Additional variables included patients' age, sex, race, modified Charlson Comorbidity Index score, mental health conditions, and medications for opioid use disorders. Factors associated with composite outcome and mortality were identified using Cox proportional hazards and reported as adjusted hazard ratio (aHR) and 95% CI. Factors associated with health care use were identified using Poisson regression and reported as adjusted incidence rate ratio (aIRR) and 95% CI. RESULTS 1,328,287 opioid prescriptions were identified for 341,722 patients. Opioid-related factors associated with the composite outcome, mortality, and hospitalizations, respectively, included opioid dosage (aHR 1.003 [95% CI 1.001-1.006]; aHR not applicable; aIRR 1.07 [1.06-1.08]), opioid days supply (aHR 1.03 [1.02-1.03]; aHR 1.009 [1.005-1.014]; aIRR 0.94 [0.92-0.96]), concurrent SA/LA opioids (aHR 2.12 [1.78-2.54]; aHR 1.40 [1.14-1.70]; aIRR 1.40 [1.37-1.42]), and use of benzodiazepines/gabapentinoids (aHR 1.68 [1.38-2.04]; aHR 1.23 [1.01-1.51]; aIRR 1.25 [1.23-1.27]). CONCLUSION Many factors are associated with poor health outcomes, especially concurrent use of SA and LA opioids and overlapping prescriptions of opioids with benzodiazepines or gabapentinoids. Identification of factors associated with adverse outcomes may help identify patients at risk for poor outcomes and could inform possible interventions.
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21
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Hikin LJ, Smith PR, Maskell PD, Kurimbokus H, Ashong E, Couchman L, Morley SR. Femoral blood concentrations of the designer benzodiazepine etizolam in post-mortem cases. MEDICINE, SCIENCE, AND THE LAW 2021; 61:122-129. [PMID: 33236683 DOI: 10.1177/0025802420973814] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Etizolam is a thienodiazepine that although licensed for clinical usage in Japan, India and South Korea is commonly abused and detected in post-mortem cases around the world. To date, there are limited data in the literature to allow for the interpretation of blood concentrations of etizolam in post-mortem cases. A liquid chromatography with tandem mass spectrometry method was used to quantitate etizolam concentrations in 28 post-mortem cases where etizolam was detected. The median concentration of etizolam in femoral blood was 8.5 ng/mL (range 1.0-172.0 ng/mL; n = 24); in antemortem plasma, the etizolam concentration range was 4-44 ng/mL (n = 4). The mean age of the individuals abusing etizolam was 38.5 ± 8.4 years (median 39 years), with the majority being male (86%). In all of the cases, multiple drugs were detected, with the most common being pregabalin (61%) followed by morphine/heroin (54%), diazepam (54%) and benzoylecgonine (21%), illustrating the increasing problem of poly-substance use in drug abusers. The cause of death in the cases in which etizolam was detected was multi-drug toxicity in 87.5% of the cases, with 12.5% unrelated to drug use (hangings and blunt-force trauma). These data will further help forensic practitioners with the interpretation of post-mortem etizolam concentrations.
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Affiliation(s)
- Laura J Hikin
- Forensic Toxicology Service, University Hospitals of Leicester NHS Trust, UK
| | - Paul R Smith
- Forensic Toxicology Service, University Hospitals of Leicester NHS Trust, UK
| | | | - Hassan Kurimbokus
- Analytical Services International, St George's University of London, UK
| | - Emily Ashong
- Analytical Services International, St George's University of London, UK
| | - Lewis Couchman
- Analytical Services International, St George's University of London, UK
| | - Stephen R Morley
- Forensic Toxicology Service, University Hospitals of Leicester NHS Trust, UK
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22
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Franklin JM, Lin KJ, Gatto NM, Rassen JA, Glynn RJ, Schneeweiss S. Real-World Evidence for Assessing Pharmaceutical Treatments in the Context of COVID-19. Clin Pharmacol Ther 2021; 109:816-828. [PMID: 33529354 PMCID: PMC8014840 DOI: 10.1002/cpt.2185] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/19/2021] [Indexed: 12/15/2022]
Abstract
The emergence and global spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in an urgent need for evidence on medical interventions and outcomes of the resulting disease, coronavirus disease 2019 (COVID-19). Although many randomized controlled trials (RCTs) evaluating treatments and vaccines for COVID-19 are already in progress, the number of clinical questions of interest greatly outpaces the available resources to conduct RCTs. Therefore, there is growing interest in whether nonrandomized real-world evidence (RWE) can be used to supplement RCT evidence and aid in clinical decision making, but concerns about nonrandomized RWE have been highlighted by a proliferation of RWE studies on medications and COVID-19 outcomes with widely varying conclusions. The objective of this paper is to review some clinical questions of interest, potential data types, challenges, and merits of RWE in COVID-19, resulting in recommendations for nonrandomized RWE designs and analyses based on established RWE principles.
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Affiliation(s)
- Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicolle M Gatto
- Aetion, Inc., New York, New York, USA.,Department of Epidemiology, Columbia University, New York, New York, USA
| | | | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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23
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Morales DR, Macfarlane T, MacDonald TM, Hallas J, Ernst MT, Herings RMC, Smits E, Overbeek JA, Mitchell L, Morant S, Mackenzie I, Doney ASF, Robertson C, Bennie M, Wei L, Nicholson L, Morris C, Flynn RWF. Impact of EMA regulatory label changes on hydroxyzine initiation, discontinuation and switching to other medicines in Denmark, Scotland, England and the Netherlands: An interrupted time series regression analysis. Pharmacoepidemiol Drug Saf 2021; 30:482-491. [PMID: 33386650 DOI: 10.1002/pds.5191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 12/11/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Hydroxyzine is indicated for the management of anxiety, skin and sleep disorders. In 2015, the European Medicines Agency (EMA) concluded that hydroxyzine was pro-arrhythmogenic and changes to the product information were implemented in Europe. This study aimed to evaluate their impact in Denmark, Scotland, England and the Netherlands. METHOD Quarterly time series analyses measuring hydroxyzine initiation, discontinuation, and switching to other antihistamines, benzodiazepines and antidepressants in Denmark, England, Scotland and the Netherlands from 2009 to 2018. Data were analysed using interrupted time series regression. RESULTS Hydroxyzine initiation in quarter one 2010 in Denmark, Scotland, England and the Netherlands per 100 000 was: 23.5, 91.5, 35.9 and 34.4 respectively. Regulatory action was associated with a significant: immediate fall in hydroxyzine initiation per 100 000 in England (-12.05, 95%CI -18.47 to -5.63) and Scotland (-19.01, 95%CI -26.99 to -11.02); change to a negative trend in hydroxyzine initiation per 100 000/quarter in England (-1.72, 95%CI -2.69 to -0.75) and Scotland (-2.38, 95%CI -3.32 to -1.44). Regulatory action was associated with a significant: immediate rise in hydroxyzine discontinuation per 100 000 in England (3850, 95%CI 440-7240). No consistent changes were observed in the Netherlands or Denmark. Regulatory action was associated with no switching to other antihistamines, benzodiazepines or antidepressants following hydroxyzine discontinuation in any country. CONCLUSION The 2015 EMA regulatory action was associated with heterogeneous impact with reductions in hydroxyzine initiation varying by country. There was limited impact on discontinuation with no strong evidence suggesting unintended consequences of major switching to other antihistamines, benzodiazepines or antidepressants.
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Affiliation(s)
- Daniel R Morales
- MEMO Research, University of Dundee, Dundee, UK.,Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | | | | | - Jesper Hallas
- Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Martin Thomsen Ernst
- Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Ron M C Herings
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | - Elisabeth Smits
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | - Jetty A Overbeek
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | | | | | | | | | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - Marion Bennie
- Strathclyde Onstitute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Li Wei
- School of Pharmacy, University College London, London, UK
| | - Lizzie Nicholson
- Electronic Data Research and Innovation Service, NHS National Services Scotland, Edinburgh, UK
| | - Carole Morris
- Electronic Data Research and Innovation Service, NHS National Services Scotland, Edinburgh, UK
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24
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Richardson K, Savva GM, Boyd PJ, Aldus C, Maidment I, Pakpahan E, Loke YK, Arthur A, Steel N, Ballard C, Howard R, Fox C. Non-benzodiazepine hypnotic use for sleep disturbance in people aged over 55 years living with dementia: a series of cohort studies. Health Technol Assess 2021; 25:1-202. [PMID: 33410736 PMCID: PMC7812417 DOI: 10.3310/hta25010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sleep disturbance affects around 60% of people living with dementia and can negatively affect their quality of life and that of their carers. Hypnotic Z-drugs (zolpidem, zopiclone and zaleplon) are commonly used to treat insomnia, but their safety and efficacy have not been evaluated for people living with dementia. OBJECTIVES To estimate the benefits and harms of Z-drugs in people living with dementia with sleep disturbance. DESIGN A series of observational cohort studies using existing data from (1) primary care linked to hospital admission data and (2) clinical cohort studies of people living with dementia. DATA SOURCES Primary care study - Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data. Clinical cohort studies - the Resource Use and Disease Course in Dementia - Nursing Homes (REDIC) study, National Alzheimer's Coordinating Centre (NACC) clinical data set and the Improving Well-being and Health for People with Dementia (WHELD) in nursing homes randomised controlled trial. SETTING Primary care study - 371 primary care practices in England. Clinical cohort studies - 47 nursing homes in Norway, 34 Alzheimer's disease centres in the USA and 69 care homes in England. PARTICIPANTS Primary care study - NHS England primary care patients diagnosed with dementia and aged > 55 years, with sleep disturbance or prescribed Z-drugs or low-dose tricyclic antidepressants, followed over 2 years. Clinical cohort studies - people living with dementia consenting to participate, followed over 3 years, 12 years and 9 months, for REDIC, NACC and WHELD, respectively. INTERVENTIONS The primary exposure was prescription or use of Z-drugs. Secondary exposures included prescription or use of benzodiazepines, low-dose tricyclic antidepressants and antipsychotics. MAIN OUTCOME MEASURES Falls, fractures, infection, stroke, venous thromboembolism, mortality, cognitive function and quality of life. There were insufficient data to investigate sleep disturbance. RESULTS The primary care study and combined clinical cohort studies included 6809 and 18,659 people living with dementia, with 3089 and 914 taking Z-drugs, respectively. New Z-drug use was associated with a greater risk of fractures (hazard ratio 1.40, 95% confidence interval 1.01 to 1.94), with risk increasing with greater cumulative dose (p = 0.002). The hazard ratio for Z-drug use and hip fracture was 1.59 (95% confidence interval 1.00 to 2.53) and for mortality was 1.34 (95% confidence interval 1.10 to 1.64). No excess risks of falls, infections, stroke or venous thromboembolism were detected. Z-drug use also did not have an impact on cognition, neuropsychiatric symptoms, disability or quality of life. LIMITATIONS Primary care study - possible residual confounding because of difficulties in identifying patients with sleep disturbance and by dementia severity. Clinical cohort studies - the small numbers of people living with dementia taking Z-drugs and outcomes not necessarily being measured before Z-drug initiation restricted analyses. CONCLUSIONS We observed a dose-dependent increase in fracture risk, but no other harms, with Z-drug use in dementia. However, multiple outcomes were examined, increasing the risk of false-positive findings. The mortality association was unlikely to be causal. Further research is needed to confirm the increased fracture risk. Decisions to prescribe Z-drugs may need to consider the risk of fractures, balanced against the impact of improved sleep for people living with dementia and that of their carers. Our findings suggest that when Z-drugs are prescribed, falls prevention strategies may be needed, and that the prescription should be regularly reviewed. FUTURE WORK More research is needed on safe and effective management strategies for sleep disturbance in people living with dementia. STUDY REGISTRATION This study is registered as European Union electronic Register of Post-Authorisation Studies (EU PAS) 18006. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - George M Savva
- School of Health Sciences, University of East Anglia, Norwich, UK
- Quadram Institute, Norwich, UK
| | - Penelope J Boyd
- School of Health Sciences, University of East Anglia, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Clare Aldus
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Ian Maidment
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Eduwin Pakpahan
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Antony Arthur
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Nicholas Steel
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
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25
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Jeong HE, Jeon HL, Oh IS, Kim WJ, Shin JY. Risk of mortality associated with concomitant antidepressant and benzodiazepine therapy among patients with depression: a population-based cohort study. BMC Med 2020; 18:387. [PMID: 33292197 PMCID: PMC7724883 DOI: 10.1186/s12916-020-01854-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/12/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND With antidepressants (ADs) having minimal therapeutic effects during the initial weeks of treatment, benzodiazepines (BZDs) are concomitantly used to alleviate depressive symptoms of insomnia or anxiety. However, with mortality risks associated with this concomitant use yet to be examined, it remains unclear as to whether this concomitant therapy offers any benefits in treating depression. METHODS We conducted a population-based cohort study using South Korea's nationwide healthcare database from 2002 to 2017. Of 2.6 million patients with depression, we identified 612,729 patients with incident depression and newly prescribed ADs or BZDs, by excluding those with a record of diagnosis or prescription within the 2 years prior to their incident diagnosis. We classified our study cohort into two discrete groups depending on the type of AD treatment received within 6 months of incident diagnosis-AD monotherapy and AD plus BZD (AD+BZD) therapy. We matched our study cohort in a 1:1 ratio using propensity scores to balance baseline characteristics and obtain comparability among groups. The primary outcome was all-cause mortality, and patients were followed until the earliest of outcome occurrence or end of the study period. We conducted multivariable Cox proportional hazards regression analysis to estimate adjusted hazards ratios (HRs) with 95% confidence intervals (CIs) for the risk of mortality associated with AD+BZD therapy versus AD monotherapy. RESULTS The propensity score-matched cohort had 519,780 patients with 259,890 patients in each group, where all baseline characteristics were well-balanced between the two groups. Compared to AD monotherapy, AD+BZD therapy was associated with an increased risk of all-cause mortality (adjusted HR, 1.04; 95% CI, 1.02 to 1.06). CONCLUSIONS Concomitantly initiating BZDs with ADs was associated with a moderately increased risk of mortality. Clinicians should therefore exercise caution when deciding to co-prescribe BZDs with ADs in treating depression, as associated risks were observed.
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Affiliation(s)
- Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Ha-Lim Jeon
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - In-Sun Oh
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Woo Jung Kim
- Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, South Korea. .,Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea. .,Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea.
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26
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Xu KY, Hartz SM, Borodovsky JT, Bierut LJ, Grucza RA. Association Between Benzodiazepine Use With or Without Opioid Use and All-Cause Mortality in the United States, 1999-2015. JAMA Netw Open 2020; 3:e2028557. [PMID: 33295972 PMCID: PMC7726637 DOI: 10.1001/jamanetworkopen.2020.28557] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Although overall rates of opioid use have been plateauing, coprescriptions of benzodiazepines and opioids have increased greatly in recent years. It is unknown whether this combination is an independent risk factor for all-cause mortality as opposed to being more frequently used by persons with a baseline elevated risk of death. OBJECTIVE To evaluate whether benzodiazepine use, with or without opioid use, is associated with increased all-cause mortality relative to the use of low-risk antidepressants. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used a large, nationally representative US data set (the National Health and Nutrition Examination Surveys [NHANES]) from 1999 to 2015. Eight cycles of NHANES data were used, spanning 37 610 person-years of follow-up time among 5212 individuals. Statistical analysis was performed from August 24, 2019, through May 23, 2020. EXPOSURES The primary exposure variable was benzodiazepine and opioid coprescriptions. Individuals taking selective serotonin reuptake inhibitors (SSRIs) served as an active comparator reference group. MAIN OUTCOMES AND MEASURES All-cause mortality was obtained via linkage of NHANES to the National Death Index. Propensity scores were calculated from covariates associated with sociodemographic factors, comorbidities, and medication use for more than 1000 prescription types. Propensity score-weighted mortality hazards were calculated from Cox proportional hazards regression models. RESULTS Of 5212 participants aged 20 years or older (1993 men [38.2%]; mean [SD] age, 54.8 [16.9] years) followed up for a median of 6.7 years (range, 0.2-16.8 years), 101 deaths (33.0 per 1000 person-years) occurred among those receiving cotreatment, 236 deaths (26.5 per 1000 person-years) occurred among those receiving only benzodiazepines, and 227 deaths (20.2 per 1000 person-years) occurred among SSRI recipients taking neither opioids nor benzodiazepines. After propensity score weighting, a significant increase in all-cause mortality was associated with benzodiazepine and opioid cotreatment (hazard ratio, 2.04 [95% CI, 1.65-2.52]) and benzodiazepines without opioids (hazard ratio, 1.60 [95% CI, 1.33-1.92]). Subgroup analyses revealed an increased risk of mortality for individuals receiving cotreatment who were 65 years or younger but not for those older than 65 years; similar findings were observed for those receiving benzodiazepines without opioids. CONCLUSIONS AND RELEVANCE This study found a significant increase in all-cause mortality associated with benzodiazepine use with or without opioid use in comparison with SSRI use. Benzodiazepine and opioid cotreatment, in particular, was associated with a 2-fold increase in all-cause mortality even after taking into account medical comorbidities and polypharmacy burden.
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Affiliation(s)
- Kevin Y. Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sarah M. Hartz
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jacob T. Borodovsky
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Laura J. Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
- Alvin J. Siteman Cancer Center, Barnes Jewish Hospital, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Richard A. Grucza
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
- Center for Health Outcomes Research, St Louis University, St Louis, Missouri
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27
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Chen TY, Winkelman JW, Mao WC, Tzeng NS, Kuo TBJ, Yang CCH, Tsai HJ, Wu CS. Real-world evidence on the use of benzodiazepine receptor agonists and the risk of venous thromboembolism. J Thromb Haemost 2020; 18:2878-2888. [PMID: 32741123 DOI: 10.1111/jth.15033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/18/2020] [Accepted: 07/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a life-threatening disease, and some studies reported that benzodiazepine receptor agonist (BZRA) use could increase the risk of VTE, but this association lacks population-based evidence. OBJECTIVES To investigate the association between BZRA use and the risk of VTE. PATIENTS/METHODS A nested case-control study analyzing Taiwan's claims database was conducted of patients with at least one new BZRA prescription on record from January 1, 2002, to December 31, 2012. We included new users who did not have any BZRA prescriptions in the preceding 2 years and identified cases with VTE and disease risk score matched control subjects. We used a logistic regression model to investigate the association between BZRA exposure and the risk of VTE. The exposure duration, dose, and classes of BZRAs were comprehensively evaluated. RESULTS We identified 2800 VTE cases and 2800 matched controls. Current BZRA prescription (≤90 days) was associated with VTE occurrence (adjusted odds ratio [aOR]: 1.83; 95% confidence interval [CI], 1.62-2.06). The point estimates of benzodiazepine hypnotics (aOR: 2.00; 95% CI, 1.45-2.76) had a marginally higher risk of VTE than nonbenzodiazepine hypnotics (aOR: 1.39; 95% CI, 1.07-1.81). The VTE risk was increased with combination BZRA use, number of BZRA used, and a higher dose of BZRA. On examination of individual BZRA, the risk of VTE was higher with flunitrazepam use (aOR: 2.99; 95% CI, 1.43-6.28) than other BZRAs. CONCLUSIONS This study presents that current BZRA use may increase the risk of VTE. Also, benzodiazepine hypnotics, especially flunitrazepam, have a higher risk of VTE.
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Affiliation(s)
- Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - John W Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wei-Chung Mao
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Terry B J Kuo
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Cheryl C H Yang
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Hui-Ju Tsai
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Chi-Shin Wu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- College of Medicine, National Taiwan University, Taipei, Taiwan
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Mathieu C, Joly P, Jacqmin-Gadda H, Wanneveich M, Bégaud B, Pariente A. Patterns of Benzodiazepine Use and Excess Risk of All-Cause Mortality in the Elderly: A Nationwide Cohort Study. Drug Saf 2020; 44:53-62. [PMID: 33125663 DOI: 10.1007/s40264-020-00992-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Despite the risks associated with their use, benzodiazepines remain used more widely than wisely. In this context, a better understanding of how their patterns of use can be associated with an increased risk of death appears essential. Indeed, the studies that investigated this association so far are inconsistent and question the influence of potential biases. OBJECTIVE The objective of this study was to investigate the association of various patterns of benzodiazepine use with all-cause mortality. METHODS A nationwide cohort of non-prevalent benzodiazepine users aged ≥ 65 years was identified using French healthcare insurance system claims databases. Exposure to benzodiazepines considered short-term, chronic (defined as a cumulated ≥ 6-month period over the previous 12 months), ongoing, and discontinued use. Using a Cox model, adjusted hazard ratios for all-cause mortality were estimated according to benzodiazepine patterns of use; exposure and confounders were treated as time-dependent variables. RESULTS In the cohort of 54,958 individuals aged ≥ 65 years, adjusted hazard ratios for all-cause mortality and benzodiazepines were 2.26 (95% confidence interval 1.96-2.61) for short-term use, 3.86 (3.04-4.90) for chronic use-discontinued, and 3.05 (2.17-4.29) for chronic use-ongoing. At age 80 years, these were 1.62 (1.48-1.79), 2.00 (1.82-2.19) and 1.13 (1.02-1.26), respectively. Adjusted hazard ratios show similar decreases with age for all patterns of benzodiazepine use. CONCLUSIONS These findings confirm the existence of an excess risk of mortality associated with benzodiazepine use and provide pattern- and age-specific estimates. Higher risks were observed for patients aged < 80 years, short-term use, or chronic use recently interrupted. If the two latter can relate to an indication bias, the associations found for ongoing chronic use and short-term use conversely support a potential causal hypothesis.
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Affiliation(s)
- Clément Mathieu
- Univ. Bordeaux, INSERM, BPH, U1219, Team Pharmacoepidemiology, Univ. Bordeaux, F-33000, Bordeaux, France
| | - Pierre Joly
- Univ. Bordeaux, INSERM, BPH, U1219, Team Biostatistics, Univ. Bordeaux, F-33000, Bordeaux, France
| | - Hélène Jacqmin-Gadda
- Univ. Bordeaux, INSERM, BPH, U1219, Team Biostatistics, Univ. Bordeaux, F-33000, Bordeaux, France
| | - Mathilde Wanneveich
- Univ. Bordeaux, INSERM, BPH, U1219, Team Biostatistics, Univ. Bordeaux, F-33000, Bordeaux, France
| | - Bernard Bégaud
- Univ. Bordeaux, INSERM, BPH, U1219, Team Pharmacoepidemiology, Univ. Bordeaux, F-33000, Bordeaux, France.,CHU Bordeaux, Pôle de Santé Publique, Centre de Pharmacovigilance de Bordeaux, Service de Pharmacologie Médicale, 33000, Bordeaux, France
| | - Antoine Pariente
- Univ. Bordeaux, INSERM, BPH, U1219, Team Pharmacoepidemiology, Univ. Bordeaux, F-33000, Bordeaux, France. .,CHU Bordeaux, Pôle de Santé Publique, Centre de Pharmacovigilance de Bordeaux, Service de Pharmacologie Médicale, 33000, Bordeaux, France.
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29
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Attin M, Abiola S, Magu R, Rosero S, Apostolakos M, Groth CM, Block R, Lin CDJ, Intrator O, Hurley D, Arcoleo K. Polypharmacy prior to in-hospital cardiac arrest among patients with cardiopulmonary diseases: A pilot study. Resusc Plus 2020; 4. [PMID: 33969325 PMCID: PMC8104360 DOI: 10.1016/j.resplu.2020.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Background Patterns of medication administration prior to in-hospital cardiac arrest (I-HCA) and the potential impact of these on patient outcomes is not well-established. Accordingly, types of medications administered in the 72 h prior to I-HCA were examined in relation to initial rhythms of I-HCA and survival. Methods A retrospective, pilot study was conducted among 96 patients who experienced I-HCA. Clinical characteristics and treatments including medications were extracted from electronic health records. Relative risk (RR) of medications or class of medications associated with the initial rhythms of I-HCA and return of spontaneous circulation (ROSC) were calculated. Results Two distinct sub-groups were identified that did not survive to hospital discharge (n = 31): 1) those who received either vasopressin/desmopressin (n = 16) and 2) those who received combinations of psychotherapeutic agents with anxiolytics, sedatives, and hypnotics (n = 15) prior to I-HCA. The risk of pulseless electrical activity and asystolic arrest was high in patients who received sympathomimetic agents alone or in combination with β-Adrenergic blocking agents, (RR = 1.40, 1.41, respectively). Vasopressin and a combination of vasopressin and fentanyl were associated with risk of unsuccessful ROSC (RR = 2.50, 2.38, respectively). Conclusions The types of medications administered during inpatient care may serve as a surrogate marker for identifying patients at risk of specific initial rhythms of I-HCA and survival.
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Affiliation(s)
- Mina Attin
- School of Nursing, University of Rochester, NY, USA
| | - Simeon Abiola
- Clinical and Translational Science Institute, School of Medicine and Dentistry, University of Rochester, NY, USA
| | - Rijul Magu
- School of Nursing, University of Rochester, NY, USA
| | - Spencer Rosero
- Division of Cardiology, Cardiac Electrophysiology, Department of Medicine, University of Rochester, NY, USA
| | - Michael Apostolakos
- Division of Pulmonary Diseases, Critical Care, Department of Medicine, University of Rochester, NY, USA
| | - Christine M Groth
- Division of Pharmacy, Department of Medicine, University of Rochester, NY, USA
| | - Robert Block
- Division of Cardiology, Department of Medicine, University of Rochester, NY, USA
| | - C D Joey Lin
- Department of Mathematics and Statistics, San Diego State University, San Diego, USA
| | - Orna Intrator
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, New York, Geriatrics & Extended Care Data & Analysis Center (GEC DAC), Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, USA
| | - Deborah Hurley
- Department of Learning and Development in the University of Rochester Medical Center, Rochester, NY, USA
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Lombardi N, Bettiol A, Crescioli G, Ravaldi C, Bonaiuti R, Venegoni M, Vighi GD, Mugelli A, Mannaioni G, Vannacci A. Risk of hospitalisation associated with benzodiazepines and z-drugs in Italy: a nationwide multicentre study in emergency departments. Intern Emerg Med 2020; 15:1291-1302. [PMID: 32333265 DOI: 10.1007/s11739-020-02339-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/06/2020] [Indexed: 12/11/2022]
Abstract
Benzodiazepines (BZD) and z-drugs (ZD) are a widely prescribed group of medicines. They are often used inappropriately, and this is associated with adverse events (AEs), which may cause emergency department (ED) visits. The present study aimed to describe the characteristics of BZD and ZD related AEs leading to emergency department (ED) visit and hospitalisation in Italy, considering their plasma half-life. Ninety-two Italian EDs were monitored between 2007 and 2018. Rates of ED visit and hospitalisation were calculated. Multivariate logistic regression was used to estimate the reporting odds ratios (RORs) of hospitalisation. Univariate linear regression was performed to evaluate the ROR of hospitalisation according the plasma half-life of the suspected agents. A total of 3203 AE reports were collected. Overall, multivariate logistic regression showed that the risk of hospitalisation was higher for prazepam (3.26 [1.31-8.11]), flurazepam (1.62 [1.15-2.27]), and lorazepam (1.36 [1.15-1.61]). In the elderly, this risk was higher for prazepam (3.98 [1.03-15.3]), and lorazepam (1.58 [1.19-2.11]). Parenteral and rectal formulations were associated with a lower risk of hospitalisation compared to oral formulations. Our findings underlined the dangers in the use of BZD and ZD in Italy, particularly in women and older adults. ED clinicians must always take into account that the higher risk in terms of hospitalisation related to the use of BZD and ZD can be observed in patients treated with oral formulations, in those exposed to more than one sedative-hypnotics, and in patients exposed to compounds with intermediate or long plasma half-life.
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Affiliation(s)
- Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Viale G. Pieraccini, 6, 50139, Florence, Italy
| | - Alessandra Bettiol
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Viale G. Pieraccini, 6, 50139, Florence, Italy
| | - Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Viale G. Pieraccini, 6, 50139, Florence, Italy
| | - Claudia Ravaldi
- Department of Health Sciences, University of Florence, 50139, Florence, Italy
| | - Roberto Bonaiuti
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Viale G. Pieraccini, 6, 50139, Florence, Italy
- Joint Laboratory of Technological Solutions for Clinical Pharmacology, Pharmacovigilance and Bioinformatics, University of Florence, 50139, Florence, Italy
| | - Mauro Venegoni
- Pharmacology Unit, Department of Diagnostics and Public Health, University of Verona, 37100, Verona, Italy
| | - Giuseppe Danilo Vighi
- Internal Medicine, Medical Department, Vimercate Hospital, ASST Di Vimercate, 20871, Vimercate, Italy
| | - Alessandro Mugelli
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Viale G. Pieraccini, 6, 50139, Florence, Italy
| | - Guido Mannaioni
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Viale G. Pieraccini, 6, 50139, Florence, Italy
- Toxicology Unit and Poison Centre, Careggi University Hospital, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Viale G. Pieraccini, 6, 50139, Florence, Italy.
- Joint Laboratory of Technological Solutions for Clinical Pharmacology, Pharmacovigilance and Bioinformatics, University of Florence, 50139, Florence, Italy.
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31
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[Profile of benzodiazepine users attending primary healthcare services in the city of Chapecó, Santa Catarina, Brazil]. Salud Colect 2020; 16:e2495. [PMID: 33147399 DOI: 10.18294/sc.2020.2495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 08/06/2020] [Indexed: 11/24/2022] Open
Abstract
Primary Health Care is a transversal point in the Psychosocial Care Network, responsible for attending to demands related to mental suffering. Although medication represents the main treatment option, the prolonged use of benzodiazepines may lead to tolerance and consequent dependence. The objective of this study is to analyze the frequency and characteristics of benzodiazepine users attending primary healthcare services, through a cross-sectional study conducted in Chapecó, Santa Catarina, a municipality in southern Brazil. Higher proportional prescription was observed in adult and elderly women, with predominance among individuals who were women (80%), white (67.9%), and married (50.7%), with a median age of 56 years. These findings suggest a need to plan and implement changes in the procedures for prescribing and administering benzodiazepines.
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32
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Understanding the effects of chronic benzodiazepine use in depression: a focus on neuropharmacology. Int Clin Psychopharmacol 2020; 35:243-253. [PMID: 32459725 DOI: 10.1097/yic.0000000000000316] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Benzodiazepines are frequently prescribed on an ongoing basis to individuals with depression, mainly to alleviate anxiety or insomnia, despite current guideline recommendations that continuous use should not exceed 4 weeks. Currently, there are no efficacy trials published beyond 8 weeks. Several antidepressant trials demonstrate that the concomitant use of a benzodiazepine is associated with poorer depressive outcomes and functional status; however, it is unclear why this is the case. Patients with depression receiving a benzodiazepine may reflect a more ill or high anxiety group, although even within anxiety disorders, the use of a benzodiazepine is associated with poorer outcomes. The neuroadaptive consequences of long-term benzodiazepine use may be a factor underlying these findings. Chronic benzodiazepine use results in decreased gamma-aminobutyric acid and monoaminergic function, as well as interference with neurogenesis, which are all purported to play a role in antidepressant efficacy. This review will discuss the oppositional neuropharmacological interactions between chronic benzodiazepine use and antidepressant mechanism of action, which could result in reduced antidepressant efficacy and function in depression.
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33
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Muzaale AD, Daubresse M, Bae S, Chu NM, Lentine KL, Segev DL, McAdams-DeMarco M. Benzodiazepines, Codispensed Opioids, and Mortality among Patients Initiating Long-Term In-Center Hemodialysis. Clin J Am Soc Nephrol 2020; 15:794-804. [PMID: 32457228 PMCID: PMC7274292 DOI: 10.2215/cjn.13341019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality from benzodiazepine/opioid interactions is a growing concern in light of the opioid epidemic. Patients on hemodialysis suffer from a high burden of physical/psychiatric conditions, which are treated with benzodiazepines, and they are three times more likely to be prescribed opioids than the general population. Therefore, we studied mortality risk associated with short- and long-acting benzodiazepines and their interaction with opioids among adults initiating hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The cohort of 69,368 adults initiating hemodialysis (January 2013 to December 2014) was assembled by linking US Renal Data System records to Medicare claims. Medicare claims were used to identify dispensed benzodiazepines and opioids. Using adjusted Cox proportional hazards models, we estimated the mortality risk associated with benzodiazepines (time varying) and tested whether the benzodiazepine-related mortality risk differed by opioid codispensing. RESULTS Within 1 year of hemodialysis initiation, 10,854 (16%) patients were dispensed a short-acting benzodiazepine, and 3262 (5%) patients were dispensed a long-acting benzodiazepine. Among those who were dispensed a benzodiazepine during follow-up, codispensing of opioids and short-acting benzodiazepines occurred among 3819 (26%) patients, and codispensing of opioids and long-acting benzodiazepines occurred among 1238 (8%) patients. Patients with an opioid prescription were more likely to be subsequently dispensed a short-acting benzodiazepine (adjusted hazard ratio, 1.66; 95% confidence interval, 1.59 to 1.74) or a long-acting benzodiazepine (adjusted hazard ratio, 1.11; 95% confidence interval, 1.03 to 1.20). Patients dispensed a short-acting benzodiazepine were at a 1.45-fold (95% confidence interval, 1.35 to 1.56) higher mortality risk compared with those without a short-acting benzodiazepine; among those with opioid codispensing, this risk was 1.90-fold (95% confidence interval, 1.65 to 2.18; Pinteraction<0.001). In contrast, long-acting benzodiazepine dispensing was inversely associated with mortality (adjusted hazard ratio, 0.84; 95% confidence interval, 0.72 to 0.99) compared with no dispensing of long-acting benzodiazepine; there was no differential risk by opioid dispensing (Pinteraction=0.72). CONCLUSIONS Codispensing of opioids and short-acting benzodiazepines is common among patients on dialysis, and it is associated with higher risk of death.
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Affiliation(s)
- Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Krista L. Lentine
- Department of Medicine, St. Louis University School of Medicine, St. Louis, Missouri
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Hassinger AB, Bletnisky N, Dudekula R, El-Solh AA. Selecting a pharmacotherapy regimen for patients with chronic insomnia. Expert Opin Pharmacother 2020; 21:1035-1043. [PMID: 32202451 DOI: 10.1080/14656566.2020.1743265] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Amanda B Hassinger
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY, USA.,VA Western New York Healthcare System , Buffalo, NY, USA
| | - Nikolas Bletnisky
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY, USA.,VA Western New York Healthcare System , Buffalo, NY, USA
| | - Rizwan Dudekula
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY, USA.,VA Western New York Healthcare System , Buffalo, NY, USA
| | - Ali A El-Solh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY, USA.,VA Western New York Healthcare System , Buffalo, NY, USA.,Department of Epidemiology and Environmental Health, Research and Development, School of Public Health, University at Buffalo , Buffalo, NY, USA
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35
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Navar AM, Peterson ED, Steen DL, Wojdyla DM, Sanchez RJ, Khan I, Song X, Gold ME, Pencina MJ. Evaluation of Mortality Data From the Social Security Administration Death Master File for Clinical Research. JAMA Cardiol 2020; 4:375-379. [PMID: 30840023 DOI: 10.1001/jamacardio.2019.0198] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Despite its documented undercapture of mortality data, the US Social Security Administration Death Master File (SSDMF) is still often used to provide mortality end points in retrospective clinical studies. Changes in death data reporting to SSDMF in 2011 may have further affected the reliability of mortality end points, with varying consequences over time and by state. Objective To evaluate the reliability of mortality rates in the SSDMF in a cohort of patients with atherosclerotic cardiovascular disease (ASCVD). Design, Setting, and Participants This observational analysis used the IBM MarketScan Medicare and commercial insurance databases linked to mortality information from the SSDMF. Adults with ASCVD who had a clinical encounter between January 1, 2012, and December 31, 2013, at least 2 years of follow-up, and from states with 1000 or more eligible adults with ASCVD were included in the study. Data analysis was conducted between April 18 and May 21, 2018. Main Outcomes and Measures Kaplan-Meier analyses were conducted to estimate state-level mortality rates for adults with ASCVD, stratified by database (commercial or Medicare). Constant hazards of mortality by state were tested, and individual state Kaplan-Meier curves for temporal changes were evaluated. For states in which the hazard of death was constant over time, mortality rates for adults with ASCVD were compared with state-level, age group-specific overall mortality rates in 2012, as reported by the National Center for Health Statistics (NCHS). Results This study of mortality data of 667 516 adults with ASCVD included 274 005 adults in the commercial insurance database cohort (171 959 male [62.8%] and median [interquartile range (IQR)] age of 58 [52-62] years) and 393 511 in the Medicare database cohort (245 366 male [62.4%] and median [IQR] age of 76 [70-83] years). Of the 41 states included, 11 states (26.8%) in the commercial cohort and 18 states (43.9%) in the Medicare cohort had a change in the hazard of death after 2012. Among states with constant hazard, state-level mortality rates using the SSDMF ranged widely, from 0.06 to 1.30 per 100 person-years (commercial cohort) and from 0.83 to 6.07 per 100 person-years (Medicare cohort). Variability between states in mortality estimates for adults with ASCVD using SSDMF data greatly exceeded variability in overall mortality from the NCHS. No correlation was found between NCHS mortality estimates and those from the SSDMF (ρ = 0.29 [P = .06] for age 55-64 years; ρ = 0.18 [P = .27] for age 65-74 years). Conclusions and Relevance The SSDMF appeared to markedly underestimate mortality rates, with variable undercapture among states and over time; this finding suggests that SSDMF data are not reliable and should not be used alone by researchers to estimate mortality rates.
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Affiliation(s)
- Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Associate Editor
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Dylan L Steen
- Associate Editor.,Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | - Xue Song
- IBM Watson Health, Cambridge, Massachusetts
| | - Matthew E Gold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Deputy Editor for Statistics
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36
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Keck ME, Nicolussi S, Spura K, Blohm C, Zahner C, Drewe J. Effect of the fixed combination of valerian, lemon balm, passionflower, and butterbur extracts (Ze 185) on the prescription pattern of benzodiazepines in hospitalized psychiatric patients-A retrospective case-control investigation. Phytother Res 2020; 34:1436-1445. [PMID: 31985131 PMCID: PMC7317844 DOI: 10.1002/ptr.6618] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 12/06/2019] [Accepted: 01/07/2020] [Indexed: 11/22/2022]
Abstract
Stress is an increasing problem that can result in various psychiatric and somatoform symptoms. Among others, benzodiazepines and valerian preparations are used to treat stress symptoms. The aim of this study was to investigate whether the prescription of a fixed herbal extract combination of valerian, lemon balm, passionflower, and butterbur (Ze 185) changes the prescription pattern of benzodiazepines in hospitalized psychiatric patients. In a retrospective case‐control study, anonymized medical record data from 3,252 psychiatric in‐house patients were analysed over a 3.5‐year period. Cases (n = 1,548) with a prescription of Ze 185 and controls (n = 1,704) were matched by age, gender, hospitalization interval, and main International Classification of Diseases, Version 10 F‐diagnoses. The primary objective was to investigate the effect of Ze 185 on the prescription pattern of benzodiazepines. Secondary objectives investigated the prescriptions of concomitant drugs and effectiveness of the hospital stay. Distribution of drug classes was analysed using the WHO's anatomic‐therapeutic‐chemical code. Data showed that both treatment modalities had a comparable clinical effectiveness but with significantly less prescriptions of benzodiazepines in the Ze 185 group (p = .006). This is of clinical importance because suitable alternatives to benzodiazepines are desirable. To obtain more support for this hypothesis, a dedicated randomized, controlled clinical trial monitoring drug safety is required.
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Affiliation(s)
- Martin E Keck
- Clienia Private Clinic Schlössli, Oetwil, Switzerland.,Psychotherapeutic Neurology, Schmieder Clinic, Gailingen, Germany
| | - Simon Nicolussi
- Medical Department, Max Zeller Söhne AG, Romanshorn, Switzerland
| | - Kerstin Spura
- Clienia Private Clinic Schlössli, Oetwil, Switzerland
| | - Cordula Blohm
- Medical Department, Max Zeller Söhne AG, Romanshorn, Switzerland
| | - Catherine Zahner
- Medical Department, Max Zeller Söhne AG, Romanshorn, Switzerland
| | - Jürgen Drewe
- Medical Department, Max Zeller Söhne AG, Romanshorn, Switzerland
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Linnet K, Sigurdsson JA, Tomasdottir MO, Sigurdsson EL, Gudmundsson LS. Association between prescription of hypnotics/anxiolytics and mortality in multimorbid and non-multimorbid patients: a longitudinal cohort study in primary care. BMJ Open 2019; 9:e033545. [PMID: 31811011 PMCID: PMC6924757 DOI: 10.1136/bmjopen-2019-033545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess the risk of mortality in primary care patients, multimorbid (≥2 chronic conditions) or not, prescribed hypnotics/anxiolytics. DESIGN A longitudinal cohort study SETTING: Primary healthcare in the Reykjavik area. PARTICIPANTS 114 084 individuals (aged 10-79 years, average 38.5, SD 18.4) contacting general practitioners during 2009-2012 (mortality follow-up to 31 December 2016). Of those, the reference group comprised 58 560 persons who were neither multimorbid nor had redeemed prescriptions for hypnotics/anxiolytics. Participants (16 108) redeeming prescriptions for hypnotics/anxiolytics on a regular basis for 3 consecutive years were considered as consistent, long-term users. They were subdivided into low-dose (1-300 defined daily doses (DDD)/3 years), medium-dose (301-1095 DDDs/3 years) and high-dose users (>1095 DDDs/3 years). All six groups taking these drugs were compared with the reference group. MAIN OUTCOME MEASURES All-cause mortality. RESULTS HRs were calculated with the no multimorbidity-no drug group as a reference, using Cox proportional hazards regression model adjusting for age, sex and the number of chronic conditions (n=111 767), patients with cancer excluded. During follow-up, 516 358 person-years in total, 1926 persons died. Mean follow-up was 1685 days (4.6 years), range 1-1826 days (5.0 years). For all multimorbid patients who took no drugs the HR was 1.14 (95% CI 1.00 to 1.30) compared with those without multimorbidity. HRs in the non-multimorbid participants varied from 1.49 to 3.35 (95% CI ranging from 1.03 to 4.11) with increasing doses of hypnotics/anxiolytics, and correspondingly from 1.55 to 3.52 (1.18 to 4.29) in multimorbid patients. CONCLUSIONS Mortality increased in a dose-dependent manner among both multimorbid and non-multimorbid patients taking hypnotics/anxiolytics. This increase was clearly associated with prescribing of these drugs. Their use should be limited to the recommended period of 2-4 up to 6 weeks; long-term use may incur increased risk and should be re-examined.
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Affiliation(s)
- Kristjan Linnet
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
| | - Johann Agust Sigurdsson
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Margret Olafia Tomasdottir
- Department of Family Medicine, Faculty of Medicine, University of Iceland School of Health Sciences, Reykjavik, Iceland
| | - Emil Larus Sigurdsson
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
- Department of Family Medicine, Faculty of Medicine, University of Iceland School of Health Sciences, Reykjavik, Iceland
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Sun EC, Mello MM, Moshfegh J, Baker LC. Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals. JAMA Intern Med 2019; 179:1543-1550. [PMID: 31403651 PMCID: PMC6692693 DOI: 10.1001/jamainternmed.2019.3451] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Although surprise medical bills are receiving considerable attention from lawmakers and the news media, to date there has been little systematic study of the incidence and financial consequences of out-of-network billing. OBJECTIVE To examine out-of-network billing among privately insured patients with an inpatient admission or emergency department (ED) visit at in-network hospitals. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis using data from the Clinformatics Data Mart database (Optum), which includes health insurance claims for individuals from all 50 US states receiving private health insurance from a large commercial insurer was conducted of all inpatient admissions (n = 5 457 981) and ED visits (n = 13 579 006) at in-network hospitals between January 1, 2010, and December 31, 2016. Data were collected and analyzed in March 2019. EXPOSURES Receipt of a bill for care from at least 1 out-of-network physician or medical transport service associated with patient admission or ED visit. MAIN OUTCOMES AND MEASURES The incidence of out-of-network billing and the potential amount of patients' financial liability associated with out-of-network bills from the admission or visit. RESULTS Of 5 457 981 inpatient admissions and 13 579 006 ED admissions between 2010 and 2016, the percentage of ED visits with an out-of-network bill increased from 32.3% to 42.8% (P < .001) during the study period, and the mean (SD) potential financial responsibility for these bills increased from $220 ($420) to $628 ($865) (P < .001; all dollar values in 2018 US$). Similarly, the percentage of inpatient admissions with an out-of-network bill increased from 26.3% to 42.0% (P < .001), and the mean (SD) potential financial responsibility increased from $804 ($2456) to $2040 ($4967) (P < .001). CONCLUSIONS AND RELEVANCE Out-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals. The mean amounts billed appear to be sufficiently large that they may create financial strain for a substantial proportion of patients.
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Affiliation(s)
- Eric C Sun
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Michelle M Mello
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, California.,Stanford Law School, Stanford, California
| | - Jasmin Moshfegh
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Laurence C Baker
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, California
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Friedrich JM, Sun C, Geng X, Calello DP, Gillam M, Medeiros KL, Smith M, Ruck B, Mazer-Amirshahi M. Child and adolescent benzodiazepine exposure and overdose in the United States: 16 years of poison center data. Clin Toxicol (Phila) 2019; 58:725-731. [DOI: 10.1080/15563650.2019.1674321] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Joseph M. Friedrich
- Harbor-UCLA Medical Center, Torrance, CA, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Christie Sun
- Kaiser Permanente South Bay Medical Center, Harbor City, CA, USA
| | - Xue Geng
- Georgetown University School of Medicine, Washington, DC, USA
| | - Diane P. Calello
- New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Rutgers, NJ, USA
| | | | | | - Mark Smith
- MedStar Institutes for Innovation, Washington, DC, USA
| | - Bruce Ruck
- New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Rutgers, NJ, USA
| | - Maryann Mazer-Amirshahi
- Georgetown University School of Medicine, Washington, DC, USA
- MedStar Washington Hospital Center, Washington, DC, USA
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Sigurdsson MI, Helgadottir S, Long TE, Helgason D, Waldron NH, Palsson R, Indridason OS, Gudmundsdottir IJ, Gudbjartsson T, Sigurdsson GH. Association Between Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery. JAMA Surg 2019; 154:e191652. [PMID: 31215988 DOI: 10.1001/jamasurg.2019.1652] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance The number of patients prescribed long-term opioids and benzodiazepines and complications from their long-term use have increased. Information regarding the perioperative outcomes of patients prescribed these medications before surgery is limited. Objective To determine whether patients prescribed opioids and/or benzodiazepines within 6 months preoperatively would have greater short- and long-term mortality and increased opioid consumption postoperatively. Design, Setting, and Participants This retrospective, single-center, population-based cohort study included all patients 18 years or older, undergoing noncardiac surgical procedures at a national hospital in Iceland from December 12, 2005, to December 31, 2015, with follow-up through May 20, 2016. A propensity score-matched control cohort was generated using individuals from the group that received prescriptions for neither medication class within 6 months preoperatively. Data analysis was performed from April 10, 2018, to March 9, 2019. Exposures Patients who filled prescriptions for opioids only, benzodiazepines only, both opioids and benzodiazepines, or neither medication within 6 months preoperatively. Main Outcomes and Measures Long-term survival compared with propensity score-matched controls. Secondary outcomes were 30-day survival and persistent postoperative opioid consumption, defined as a prescription filled more than 3 months postoperatively. Results Among 41 170 noncardiac surgical cases in 27 787 individuals (16 004 women [57.6%]; mean [SD] age, 56.3 [18.8] years), a preoperative prescription for opioids only was filled for 7460 cases (17.7%), benzodiazepines only for 3121 (7.4%), and both for 2633 (6.2%). Patients who filled preoperative prescriptions for either medication class had a greater comorbidity burden compared with patients receiving neither medication class (Elixhauser comorbidity index >0 for 16% of patients filling prescriptions for opioids only, 22% for benzodiazepines only, and 21% for both medications compared with 14% for patients filling neither). There was no difference in 30-day (opioids only: 1.3% vs 1.0%; P = .23; benzodiazepines only: 1.9% vs 1.5%; P = .32) or long-term (opioids only: hazard ratio [HR], 1.12 [95% CI, 1.01-1.24]; P = .03; benzodiazepines only: HR, 1.11 [95% CI, 0.98-1.26]; P = .11) survival among the patients receiving opioids or benzodiazepines only compared with controls. However, patients prescribed both opioids and benzodiazepines had greater 30-day mortality (3.2% vs 1.8%; P = .004) and a greater hazard of long-term mortality (HR, 1.41; 95% CI, 1.22-1.64; P < .001). The rate of persistent postoperative opioid consumption was higher for patients filling prescriptions for opioids only (43%), benzodiazepines only (23%), or both (66%) compared with patients filling neither (12%) (P < .001 for all). Conclusions and Relevance The findings suggest that opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption. These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.
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Affiliation(s)
- Martin I Sigurdsson
- Division of Anesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Solveig Helgadottir
- Division of Anesthesia and Intensive Care Medicine, Akademiska University Hospital, Uppsala, Sweden
| | - Thorir E Long
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Internal Medicine Services, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Dadi Helgason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Internal Medicine Services, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Nathan H Waldron
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina
| | - Runolfur Palsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Internal Medicine Services, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Division of Nephrology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Olafur S Indridason
- Internal Medicine Services, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Division of Nephrology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Ingibjorg J Gudmundsdottir
- Internal Medicine Services, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Division of Cardiology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Tomas Gudbjartsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Division of Cardiothoracic Surgery, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Gisli H Sigurdsson
- Division of Anesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Strålin P, Hetta J. Medication, hospitalizations and mortality in 5 years after first-episode psychosis in a Swedish nation-wide cohort. Early Interv Psychiatry 2019; 13:902-907. [PMID: 29888512 DOI: 10.1111/eip.12697] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/03/2018] [Accepted: 05/16/2018] [Indexed: 12/13/2022]
Abstract
AIM To investigate medication, rehospitalizations and mortality after first-episode hospital-treated psychosis. METHODS A population-based nation-wide cohort (n = 2488) with a first hospitalization for psychosis at ages between 16 and 25 was identified. Cases were followed for up to 5 years after the first psychosis hospitalization with regard to mortality, hospitalizations and dispensations of antipsychotics and benzodiazepines. RESULTS The proportion of patients dispensing antipsychotics decreased from 80% year 1 after first discharge to 55% year 5. The proportion of patients having episodes of inpatient care also decreased year by year from 46% year 1 to 27% year 5. Of 863 cases with 5 years of observation time 41% had dispensations of antipsychotics every year; 21% had no dispensation of antipsychotics or hospitalization after the first year. The cumulative 5-year mortality was 3.9%. Cumulative suicide mortality was 2.4%. Incidence of suicide was highest in the first year. Male gender, benzodiazepines, recent hospital-discharge and self-harm were identified as risk factors for suicide. CONCLUSIONS The proportion of cases dispensing antipsychotics decreases year by year after first discharge. Mortality and rates of rehospitalization also decrease year by year from high levels the first year.
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Affiliation(s)
- Pontus Strålin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jerker Hetta
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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42
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Richardson K, Mattishent K, Loke YK, Steel N, Fox C, Grossi CM, Bennett K, Maidment I, Boustani M, Matthews FE, Myint PK, Campbell NL, Brayne C, Robinson L, Savva GM. History of Benzodiazepine Prescriptions and Risk of Dementia: Possible Bias Due to Prevalent Users and Covariate Measurement Timing in a Nested Case-Control Study. Am J Epidemiol 2019; 188:1228-1236. [PMID: 31111865 PMCID: PMC6601519 DOI: 10.1093/aje/kwz073] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 03/14/2019] [Accepted: 03/14/2019] [Indexed: 02/01/2023] Open
Abstract
Previous estimates of whether long-term exposure to benzodiazepines increases dementia risk are conflicting and are compromised by the difficulty of controlling for confounders and by reverse causation. We investigated how estimates for the association between benzodiazepine use and later dementia incidence varied based on study design choices, using a case-control study nested within the United Kingdom's Clinical Practice Research Datalink. A total of 40,770 dementia cases diagnosed between April 2006 and July 2015 were matched on age, sex, available data history, and deprivation to 283,933 control subjects. Benzodiazepines and Z-drug prescriptions were ascertained in a drug-exposure period 4-20 years before dementia diagnosis. Estimates varied with the inclusion of new or prevalent users, with the timing of covariate ascertainment, and with varying time between exposure and outcome. There was no association between any new prescription of benzodiazepines and dementia (adjusted odds ratio (OR) = 1.03, 95% confidence interval (CI): 1.00, 1.07), whereas an inverse association was observed among prevalent users (adjusted OR = 0.91, 95% CI: 0.87, 0.95), although this was likely induced by unintentional adjustment for colliders. By considering the choice of confounders and timing of exposure and covariate measurement, our findings overall are consistent with no causal effect of benzodiazepines or Z-drugs on dementia incidence.
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Affiliation(s)
- Kathryn Richardson
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | | | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Nicholas Steel
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Carlota M Grossi
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ian Maidment
- School of Life and Health Sciences, Aston University, Birmingham, United Kingdom
| | - Malaz Boustani
- School of Medicine, Indiana University, Indianapolis, Indiana
| | - Fiona E Matthews
- Institute of Health and Society/Institute for Ageing, Newcastle University, Newcastle, United Kingdom
| | - Phyo K Myint
- School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Noll L Campbell
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, Lafayette, Indiana
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
| | - Louise Robinson
- Institute of Health and Society/Institute for Ageing, Newcastle University, Newcastle, United Kingdom
| | - George M Savva
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
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O'Donnell SB, Nicholson MK, Boland JW. The Association Between Benzodiazepines and Survival in Patients With Cancer: A Systematic Review. J Pain Symptom Manage 2019; 57:999-1008.e11. [PMID: 30708126 DOI: 10.1016/j.jpainsymman.2019.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 01/25/2023]
Abstract
CONTEXT Patients with cancer often experience distressing symptoms such as anxiety or dyspnea, which can be managed with benzodiazepines; however, concerns regarding the impact of these drugs on survival may dissuade prescribing and compliance. OBJECTIVES We aimed to identify and appraise studies examining benzodiazepine use and survival in adults with cancer, to investigate the relationship and context of use. METHODS Systematic review of the international literature prepared according to preferred reporting items for systematic reviews. Comprehensive searches of the MEDLINE, Embase, PsycINFO, Cochrane Library, and AMED databases using medical subject heading and free-text search combinations with no date or language restrictions were undertook. Handsearching of references was conducted. Risk of bias of the included studies was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS Two thousand two hundred fifty-seven unique records were identified, with 18 meeting inclusion criteria, representing 4117 patients. All studies were very low quality. No study found an increase in mortality in association with benzodiazepine use, whereas two demonstrated an increase. CONCLUSION Existing evidence shows no association between benzodiazepine use in patients with cancer and decreased survival. None of the studies evaluated the association between benzodiazepine use and survival in earlier stages of cancer, and the quality of studies retrieved signifies a need for further robust studies to draw more definitive conclusions. Further investigation in patients with cancer using well-designed, high-quality research with survival as a primary outcome should be conducted.
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Affiliation(s)
- Sean B O'Donnell
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | | | - Jason W Boland
- Hull York Medical School, University of Hull, Hull, United Kingdom
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Tevik K, Selbæk G, Engedal K, Seim A, Krokstad S, Helvik AS. Mortality in older adults with frequent alcohol consumption and use of drugs with addiction potential - The Nord Trøndelag Health Study 2006-2008 (HUNT3), Norway, a population-based study. PLoS One 2019; 14:e0214813. [PMID: 30990815 PMCID: PMC6467384 DOI: 10.1371/journal.pone.0214813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/20/2019] [Indexed: 12/19/2022] Open
Abstract
Background The aim of this study was to investigate whether frequent drinking, use of drugs with addiction potential and the possible combination of frequent drinking and use of prescribed drugs with addiction potential were associated with all-cause mortality in older adults. Methods We used data from the Nord-Trøndelag Health Study (HUNT3 2006–08), a population-based study in Norway. A total of 11,545 (6,084 women) individuals 65 years and older at baseline participated. We assessed frequent drinking (≥ 4 days a week), occasional drinking (i.e. a few times a year), never drinking and non-drinking in the last year. Drugs with addiction potential were defined as at least one prescription of benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years between 2005 and 2009. This information was drawn from the Norwegian Prescription Database. The main outcome was all-cause mortality with information drawn from the Norwegian Cause of Death Registry. Follow-up continued until death or latest at 31 December 2013. Logistic regression analyses were used to investigate all-cause mortality since date of study entry and exact age at time of death was unknown. Results The adjusted logistic regression analyses showed that frequent drinking was not associated with all-cause mortality compared to occasional drinking. Men who reported to be never drinkers and non-drinkers in the last year had higher odds of mortality compared to those who drank occasionally. Use of prescribed drugs with addiction potential was associated with increased mortality in men, but not in women. No association was found between the possible combination of frequent drinking and use of prescribed drugs with addiction potential and mortality. Conclusion Neither frequent drinking nor the possible combination of frequent drinking and use of prescribed drugs with addiction potential were associated with all-cause mortality in older women and men. Use of prescribed drugs with addiction potential was associated with higher odds of mortality in men. This finding should lead to more caution in prescribing drugs with addiction potential to this group.
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Affiliation(s)
- Kjerstin Tevik
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- * E-mail:
| | - Geir Selbæk
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- The Research Centre for Age-related Functional Decline and Disease, Innlandet Hospital Trust, Ottestad, Norway
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Knut Engedal
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Arnfinn Seim
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Steinar Krokstad
- HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, (NTNU), Levanger, Norway
- Psychiatric Department, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Anne-S Helvik
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- St. Olavs University Hospital, Sluppen, Trondheim, Norway
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Antipsychotic utilization patterns among patients with schizophrenic disorder: a cross-national analysis in four countries. Eur J Clin Pharmacol 2019; 75:1005-1015. [PMID: 30824947 DOI: 10.1007/s00228-019-02654-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/20/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE The aim of the present study was to describe antipsychotic utilization patterns among patients with schizophrenic disorder in Italy, Spain, the UK, and the USA. METHODS A retrospective cohort study was conducted. Patients aged 15 and over with schizophrenic disorder were identified in the Caserta claims database (Italy), the Valencia electronic medical record (EMR) database (Spain), in The Health Improvement Network EMR database (UK), and in databases of publicly and privately insured populations in the United States (US). RESULTS The frequency of first-generation or second-generation antipsychotic use and of long-acting or other formulations was described. Persistence to antipsychotics was estimated. Overall, 1,403,240 patients with schizophrenic disorder having a total of 765,573 new antipsychotic treatment episodes were identified. The median follow-up time ranged from 0.8 (IQR 0.2-1.9) years in the US commercially-insured population to 1.2 (IQR 0.1-1.7) years in the Spanish population. Second-generation antipsychotics were more frequently used than first-generation antipsychotics in all countries (on average, from 64.4% in the UK to 87% in US): the use of this class increased over time in Italy, Spain, and US (Medicaid). The use of long-acting formulations was heterogeneous across countries, but generally much lower than other formulations. Persistence to antipsychotic treatment at 1 year was low in all countries, ranging from 40 in Spain to 30% in Italy. CONCLUSIONS Antipsychotic utilization was heterogeneous among persons with schizophrenic disorder. Nevertheless, low persistence was an issue in all the countries, as less than half of the patients continued their treatment beyond 1 year.
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D’Arcy M, Stürmer T, Lund JL. The importance and implications of comparator selection in pharmacoepidemiologic research. CURR EPIDEMIOL REP 2018; 5:272-283. [PMID: 30666285 PMCID: PMC6338470 DOI: 10.1007/s40471-018-0155-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Pharmacoepidemiologic studies employing large databases are critical to evaluating the effectiveness and safety of drug exposures in large and diverse populations. Because treatment is not randomized, researchers must select a relevant comparison group for the treatment of interest. The comparator group can consist of individuals initiating: (1) a similarly indicated treatment (active comparator), (2) a treatment used for a different indication (inactive comparator) or (3) no particular treatment (non-initiators). Herein we review recent literature and describe considerations and implications of comparator selection in pharmacoepidemiologic studies. RECENT FINDINGS Comparator selection depends on the scientific question and feasibility constraints. Because pharmacoepidemiologic studies rely on the choice to initiate or not initiate a specific treatment, rather than randomization, they are at-risk for confounding related to the comparator choice including: by indication, disease severity and frailty. We describe forms of confounding specific to pharmacoepidemiologic studies and discuss each comparator along with informative examples and a case study. We provide commentary on potential issues relevant to comparator selection in each study, highlighting the importance of understanding the population in whom the treatment is given and how patient characteristics are associated with the outcome. SUMMARY Advanced statistical techniques may be insufficient for reducing confounding in observational studies. Evaluating the extent to which comparator selection may mitigate or induce systematic bias is a critical component of pharmacoepidemiologic studies.
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Affiliation(s)
- Monica D’Arcy
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jennifer L. Lund
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients. Drugs Aging 2018; 35:493-521. [PMID: 29705831 DOI: 10.1007/s40266-018-0544-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and 'one-off' geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.
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Ponté C, Lepelley M, Boucherie Q, Mallaret M, Lapeyre Mestre M, Pradel V, Micallef J. Doctor shopping of opioid analgesics relative to benzodiazepines: A pharmacoepidemiological study among 11.7 million inhabitants in the French countries. Drug Alcohol Depend 2018; 187:88-94. [PMID: 29649695 DOI: 10.1016/j.drugalcdep.2018.01.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND The abuse of prescription opioids and its subsequent consequences is an important public concern particularly in the USA. The literature on opioid analgesic abuse is scarce. OBJECTIVE We assess the extent and risk of opioid analgesics abuse relative to benzodiazepines (BZD) using the doctor shopping method, taken into account the pharmacological characteristics (dosage, route of administration, extended or immediate release). METHODS We used SNIIRAM database covering 11.7 million inhabitants. All individuals with at least one reimbursement for non-injectable opioid analgesic or BZD in 2013 were included. Opioids for mild to moderate pain and for moderately severe to severe pain were studied. The Doctor Shopping Quantity (DSQ) is the quantity obtained by overlapping prescriptions from several prescribers. The Doctor Shopping Indicator (DSI) is the DSQ divided by the total dispensed quantity. RESULTS The strong opioid analgesics have the highest DSI (2.79%) versus 2.06% for BZD hypnotics. Flunitrazepam ranked first according to its DSI (13.2%), followed by morphine (4%), and zolpidem (2.2%). The three-strong opioids having the highest DSI were morphine, oxycodone and fentanyl (respectively 4%, 1.7% and 1.5%). The highest DSI was observed for the highest dosages of morphine (DSI = 8.4% for 200 mg) and oxycodone (DSI = 2.8% for 80 mg). The highest DSI for fentanyl was described with nasal and transmucosal forms (4.1% and 3.3% respectively). The highest DSI for morphine was described for extended-release (4.1%). CONCLUSION There is a need to reinforce surveillance systems to track opioid misuse and to increase awareness of healthcare professionals.
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Affiliation(s)
- Camille Ponté
- Centre d'Evaluation et d'Information de la Pharmacodépendance-Addictovigilance, Service de Pharmacologie Médicale et Clinique, CIC 1436, UMR 1027 Inserm-Université Paul Sabatier Toulouse III, France
| | - Marion Lepelley
- Centre d'Evaluation et d'Information de la Pharmacodépendance-Addictovigilance, Centre hospitalo-universitaire de Grenoble, 38043 Grenoble cedex, France
| | - Quentin Boucherie
- Centre d'Evaluation et d'Information de la Pharmacodépendance-Addictovigilance PACA-Corse, Service de Pharmacologie clinique, Aix-Marseille Université, Institut des Neurosciences des Systèmes UMR INSERM 1106, Marseille, France
| | - Michel Mallaret
- Centre d'Evaluation et d'Information de la Pharmacodépendance-Addictovigilance, Centre hospitalo-universitaire de Grenoble, 38043 Grenoble cedex, France
| | - Maryse Lapeyre Mestre
- Centre d'Evaluation et d'Information de la Pharmacodépendance-Addictovigilance, Service de Pharmacologie Médicale et Clinique, CIC 1436, UMR 1027 Inserm-Université Paul Sabatier Toulouse III, France
| | - Vincent Pradel
- Centre d'Evaluation et d'Information de la Pharmacodépendance-Addictovigilance PACA-Corse, Centre Associé, hôpital Sainte Marguerite, Laboratoire de Santé Publique, Faculté de médecine, EA 3279, Marseille, France
| | - Joëlle Micallef
- Centre d'Evaluation et d'Information de la Pharmacodépendance-Addictovigilance PACA-Corse, Service de Pharmacologie clinique, Aix-Marseille Université, Institut des Neurosciences des Systèmes UMR INSERM 1106, Marseille, France.
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Saarelainen L, Tolppanen AM, Koponen M, Tanskanen A, Tiihonen J, Hartikainen S, Taipale H. Risk of death associated with new benzodiazepine use among persons with Alzheimer disease: A matched cohort study. Int J Geriatr Psychiatry 2018; 33:583-590. [PMID: 29143367 DOI: 10.1002/gps.4821] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 09/27/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the risk of death associated with new benzodiazepine and related drug (BZDR) use in a nationwide cohort of persons with Alzheimer disease (AD). METHODS The register-based MEDALZ cohort, including all community-dwelling Finns diagnosed with AD during 2005 to 2011 (n = 70 718), was used. Clinically verified AD diagnoses were obtained from the Special Reimbursement Register. Drug use periods were modeled from BZDR purchases, derived from the Prescription Register. To study new users, persons who had any BZDR use during the year preceding the AD diagnosis were excluded. For each person initiating BZDR use (n = 10 380), 2 nonusers (n = 20 760) were matched on age, gender, and time since AD diagnosis. The outcome was 180-day mortality, and BZDR use was compared with nonuse with Cox regression. Multivariable analyses were adjusted for Charlson comorbidity index, socioeconomic position, hip fractures, psychiatric disorders, substance abuse, stroke, and other psychotropic drug use. RESULTS During the follow-up, 5 excess deaths per 100 person-years occurred during BZDR use in comparison to nonuse, and mortality rates were 13.4 (95% confidence interval [CI], 12.2-14.5) and 8.5 (95% CI, 7.9-9.1), respectively. Benzodiazepine and related drug use was associated with an increased risk of death (adjusted hazard ratio = 1.4 [95% CI, 1.2-1.6]), and the association was significant from the initiation of use. Benzodiazepine use was associated with an increased risk of death, whereas benzodiazepine-related drug use was not. CONCLUSIONS Benzodiazepine and related drug use was associated with an increased risk of death in persons with AD. Our results support treatment guidelines stating that nonpharmacological approaches should be the first-line option for symptomatic treatment of AD.
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Affiliation(s)
- Laura Saarelainen
- Kuopio Research Centre for Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Anna-Maija Tolppanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety, University of Eastern Finland, Kuopio, Finland
| | - Marjaana Koponen
- Kuopio Research Centre for Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Impact Assessment Unit, National Institute for Health and Welfare, Helsinki, Finland.,Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland.,Stockholm County Council, Stockholm, Sweden
| | - Sirpa Hartikainen
- Kuopio Research Centre for Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Department of Psychiatry, Kuopio University Hospital, Kuopio, Finland
| | - Heidi Taipale
- Kuopio Research Centre for Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Yu X, Franks NP, Wisden W. Sleep and Sedative States Induced by Targeting the Histamine and Noradrenergic Systems. Front Neural Circuits 2018; 12:4. [PMID: 29434539 PMCID: PMC5790777 DOI: 10.3389/fncir.2018.00004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/11/2018] [Indexed: 01/07/2023] Open
Abstract
Sedatives target just a handful of receptors and ion channels. But we have no satisfying explanation for how activating these receptors produces sedation. In particular, do sedatives act at restricted brain locations and circuitries or more widely? Two prominent sedative drugs in clinical use are zolpidem, a GABAA receptor positive allosteric modulator, and dexmedetomidine (DEX), a selective α2 adrenergic receptor agonist. By targeting hypothalamic neuromodulatory systems both drugs induce a sleep-like state, but in different ways: zolpidem primarily reduces the latency to NREM sleep, and is a controlled substance taken by many people to help them sleep; DEX produces prominent slow wave activity in the electroencephalogram (EEG) resembling stage 2 NREM sleep, but with complications of hypothermia and lowered blood pressure—it is used for long term sedation in hospital intensive care units—under DEX-induced sedation patients are arousable and responsive, and this drug reduces the risk of delirium. DEX, and another α2 adrenergic agonist xylazine, are also widely used in veterinary clinics to sedate animals. Here we review how these two different classes of sedatives, zolpidem and dexmedetomideine, can selectively interact with some nodal points of the circuitry that promote wakefulness allowing the transition to NREM sleep. Zolpidem enhances GABAergic transmission onto histamine neurons in the hypothalamic tuberomammillary nucleus (TMN) to hasten the transition to NREM sleep, and DEX interacts with neurons in the preoptic hypothalamic area that induce sleep and body cooling. This knowledge may aid the design of more precise acting sedatives, and at the same time, reveal more about the natural sleep-wake circuitry.
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Affiliation(s)
- Xiao Yu
- Department of Life Sciences, Imperial College London, London, United Kingdom
| | - Nicholas P Franks
- Department of Life Sciences, Imperial College London, London, United Kingdom.,Centre for Neurotechnology, Imperial College London, London, United Kingdom.,UK Dementia Research Institute, Imperial College London, London, United Kingdom
| | - William Wisden
- Department of Life Sciences, Imperial College London, London, United Kingdom.,Centre for Neurotechnology, Imperial College London, London, United Kingdom.,UK Dementia Research Institute, Imperial College London, London, United Kingdom
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