Caffeine-Containing Medicines Increase the Risk of Hemorrhagic Stroke

10th Anniversary of Asia Pacific Stroke Organization: State of Stroke Care and Stroke Research in the Asia Pacific

The Asia Pacific Stroke Organization is the largest international and professional stroke group in the region. It has worked consistently over the last 10 years to gain visibility and consistency across the Asia-Pacific and beyond. The 10-year journey will be reviewed in the background of many internal and external developments including changes in Asia-Pacific stroke epidemiology, stroke care systems, and stroke service developments as well as major research studies in the Asia-Pacific.

The Relationship Between Caffeine and Caffeinated Drinks in Causing Intracranial Hemorrhage in the Elderly Aspirin-Taking Population: A Systematic Review

Caffeinated drinks are the most widely consumed beverages globally and their intake has increased in the elderly. Caffeine exhibits dose-dependent adverse effects. Low to moderate doses cause anxiety, restlessness, irritability, and nausea. High doses of 3-5g can affect different physiological systems and lead to detrimental effects like palpitations, hypertension, agitation, seizures, and coma. Low-dose aspirin is the most used anticoagulant in preventing ischemic vascular events. An increased risk of intracranial hemorrhage is associated with low-dose aspirin with an intensified intracerebral hemorrhage risk. The aim of this research is to explore the association between caffeine and aspirin in causing lethal intracranial hemorrhage in the older population. Because of the devastating nature of intracranial hemorrhages and the inconsistent published data on the risk of intracranial hemorrhage in individuals taking both aspirin and caffeine, we conducted a systematic review considering the elderly population. We conducted the study following the reporting guidelines for systematic review and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Inclusion and exclusion criteria were determined. Data was collected from PubMed, PubMed Central® (PMC), National Library of Medicine (MEDLINE), Google Scholar, Multidisciplinary Digital Publishing Institute (MDPI), and Web of Science by applying keywords and Medical Subject Headings (MeSH) terms individually. Our initial search yielded 155,270 articles, which were scrutinized, and duplicates were removed for accuracy. Of these, a total of 13 research papers were finally extracted using the PRISMA recommendations and applying other inclusion and exclusion criteria. With the help of our systematic review, we could determine that both aspirin and caffeine portrayed a role in causing intracranial hemorrhage independently, but further studies are recommended to evaluate if both could lead to similar adverse effects when taken collectively.

Coffee Consumption and Cardiovascular Diseases: A Mendelian Randomization Study

Coffee consumption has been linked to a lower risk of cardiovascular disease in observational studies, but whether the associations are causal is not known. We conducted a Mendelian randomization investigation to assess the potential causal role of coffee consumption in cardiovascular disease. Twelve independent genetic variants were used to proxy coffee consumption. Summary-level data for the relations between the 12 genetic variants and cardiovascular diseases were taken from the UK Biobank with up to 35,979 cases and the FinnGen consortium with up to 17,325 cases. Genetic predisposition to higher coffee consumption was not associated with any of the 15 studied cardiovascular outcomes in univariable MR analysis. The odds ratio per 50% increase in genetically predicted coffee consumption ranged from 0.97 (95% confidence interval (CI), 0.63, 1.50) for intracerebral hemorrhage to 1.26 (95% CI, 1.00, 1.58) for deep vein thrombosis in the UK Biobank and from 0.86 (95% CI, 0.50, 1.49) for subarachnoid hemorrhage to 1.34 (95% CI, 0.81, 2.22) for intracerebral hemorrhage in FinnGen. The null findings remained in multivariable Mendelian randomization analyses adjusted for genetically predicted body mass index and smoking initiation, except for a suggestive positive association for intracerebral hemorrhage (odds ratio 1.91; 95% CI, 1.03, 3.54) in FinnGen. This Mendelian randomization study showed limited evidence that coffee consumption affects the risk of developing cardiovascular disease, suggesting that previous observational studies may have been confounded.

Direct oral anticoagulants: a review on the current role and scope of reversal agents

New guideline recommendations prefer direct oral anticoagulants (DOACs) over warfarin in DOAC-eligible patients with atrial fibrillation and patients with venous thromboembolism. As expected with all antithrombotic agents, there is an associated increased risk of bleeding complications in patients receiving DOACs that can be attributed to the DOAC itself, or other issues such as acute trauma, invasive procedures, or underlying comorbidities. For the majority of severe bleeding events, the widespread approach is to withdraw the DOAC, then provide supportive measures and "watchful waiting" with the expectation that the bleeding event will resolve with time. However, urgent reversal of anticoagulation may be advantageous in patients with serious or life-threatening bleeding or in those requiring urgent surgery or procedures. Until recently, the lack of specific reversal agents, has affected the uptake of these agents in clinical practice despite a safer profile compared to warfarin in clinical trials. In cases of life-threatening or uncontrolled bleeding or when patients require emergency surgery or urgent procedures, idarucizumab has been recently approved for reversal of anticoagulation in dabigatran-treated patients and andexanet alfa for factor Xa inhibitor-treated treated patients. The current review summarizes the current clinical evidence and scope of these agents with the potential impact on DOAC use in clinical practice.

Reversal Strategies for Intracranial Hemorrhage Related to Direct Oral Anticoagulant Medications

Direct oral anticoagulants (DOACs) are a new class of anticoagulants that directly inhibit either thrombin or factor Xa in the coagulation cascade. They are being increasingly used instead of warfarin or other vitamin K antagonists (VKAs). Adverse side effects of DOACs may result in hemorrhagic complications, including life-threatening intracranial hemorrhage (ICH), though to a much lesser degree than VKAs. Currently there are relatively limited indications for DOACS but their usage is certain to expand with the availability of their respective specific reversal agents. Currently, only idarucizumab (antidote for dabigatran) has been United States Food and Drug Administration- (FDA-) approved, but others (andexanet-α and ciraparantag) may be approved in near future, and the development and availability of such reversal agents have the potential to dramatically change the current anticoagulant use by providing reversal of multiple oral anticoagulants. Until all the DOACs have FDA-approved reversal agents, the treatment of the dreaded side effects of bleeding is challenging. This article is an attempt to provide an overview of the management of hemorrhage, especially ICH, related to DOAC use.

Over-the-counter analgesic powder use in patients presenting with intracerebral hemorrhage: A case series

INTRODUCTION

Over-the-counter (OTC) analgesics including aspirin-containing powder formulations (BC Powder, Goody's Powder) (ACPFs) are commonly utilized in the United States. While the ACPFs have been associated with upper gastrointestinal bleeding, we describe a case series of patients presenting with intracerebral hemorrhage (ICH) within 24 hours of ingestion.

METHODS

We reviewed all ICH patients presenting to a comprehensive stroke center from September 1, 2014 through June 30, 2016 to identify patients who reported taking BC Powder or Goody's Powder within 7 days of their stroke. Baseline characteristics, medication use, stroke risk factors, clinical imaging, and laboratory testing were reviewed retrospectively.

RESULTS

Of 334 patients admitted with ICH during the study period, 6 (2%) reported use of OTC analgesic powders within 1 week of their index stroke. All had consumed at least 1 packet within 24 hours of their ICH. All patients were African American and all except 1 patient were females. Three patients had no identified traditional stroke risk factors and 3 other patients had evidence of mild hypertension history.

CONCLUSIONS

Over-the-counter analgesic powders containing high doses of aspirin including BC Powder and Goody's Powder may contribute to ICH in patients with no or minimal risk factors. Providers should inquire about the use of these powders in ICH patients particularly among African Americans.

Coffee-Antihypertensive Drug Interaction: A Hemodynamic and Pharmacokinetic Study With Felodipine

OBJECTIVES

A period of abstinence from coffee to permit caffeine elimination appears to enable increased blood pressure on subsequent exposure. We hypothesized that this would offset the antihypertensive effect of the dihydropyridine calcium channel blocker felodipine.

METHODS

A randomized, single-dose, crossover study assessed hemodynamic and pharmacokinetic effects following 2 days without coffee and caffeine-containing foods. Consistently brewed black coffee (2×300ml), felodipine maximum recommended dose (10mg), and coffee plus felodipine were tested in middle-aged normotensive subjects.

RESULTS

Pretreatment plasma caffeine concentrations were unquantifiable. After coffee, blood pressure changes (mm Hg) averaged over study hours 1-4 were increased for brachial systolic (7.6, P < 0.001) and diastolic (4.9, P < 0.001) and aortic systolic (7.4, P < 0.001), pulse (3.0, P < 0.05) and augmentation (1.4, P < 0.05) relative to baseline. After coffee plus felodipine, they were higher for brachial systolic (4.0, P < 0.05) and diastolic (3.9, P < 0.001) and aortic systolic (4.6, P < 0.05) compared to felodipine alone. The pressor effects of coffee and its modulation by felodipine were variable among individuals. Coffee containing caffeine (127mg) caused maximum pressor effect. Caffeine and felodipine pharmacokinetics were similar for coffee and felodipine given alone or in combination indicating an interaction having a pharmacodynamic basis. Plasma felodipine concentration-diastolic blood pressure reduction relationship shifted with coffee such that doubling the felodipine concentration would eliminate the pressor effect. However, this may increase the risk of adverse drug events particularly during the timeframe without coffee.

CONCLUSION

Intermittent coffee ingestion might complicate hypertension diagnosis and management for many individuals.

Prolonged sleep increases the risk of intracerebral haemorrhage: a nationwide case-control study

BACKGROUND AND PURPOSE

Although abnormal sleep duration is positively associated with increased risk for cardiovascular disease and mortality, the specific impact on intracerebral haemorrhage (ICH) risk remains unclear. The relationship between sleep duration and the risk of ICH was investigated in our study.

METHODS

A nationwide, multicentre matched case-control study was performed to investigate the risk factors for haemorrhagic stroke, using patients from 33 hospitals in Korea. In all, 490 patients with ICH and 980 age- and sex-matched controls were enrolled. Detailed information regarding sleep, sociodemographic factors, lifestyle and medical history before ICH onset was obtained using qualified structured questionnaires. Sleep duration was categorized and the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a conditional logistic regression with 7 h as the reference duration.

RESULTS

The number of subjects with long sleep duration, more than 8 h, was significantly greater in the ICH group than in the control group (≥8 h, 30.4% vs. 22.6%, P = 0.002). After controlling for relevant confounding factors, longer sleep duration was found to be independently associated with the risk of ICH in a dose-response manner (8 h, OR 1.57, 95% CI 1.00-2.47; ≥9 h, OR 5.00, 95% CI 2.18-11.47).

CONCLUSIONS

Our study suggested that long sleep duration is positively associated with an increased ICH risk in a dose-dependent manner. Further studies on the relationship linking long sleep duration with increased risk of ICH are required.

A long-term risk-benefit analysis of low-dose aspirin in primary prevention

BACKGROUND

The long-term risk-benefit effect of occasional and regular use of low-dose aspirin (≤ 100 mg per day) in primary prevention of vascular diseases and cancers was calculated.

METHODS

One representative database of 1 000 000 participants from Taiwan's National Health Insurance scheme in 1997-2000 was used. The potential study subjects were those aged 30-95 years, were found not to have been prescribed aspirin before 1 January 2000, but to have first been prescribed low-dose aspirin (≤ 100 mg per day) after that date and were followed up to 31 December 2009. Participants prescribed low-dose aspirin < 20% during the study period were considered occasional users and those prescribed ≥ 80% regular users. After the propensity score matching, rate differences of haemorrhage, ischaemia and cancer between these users were calculated their net clinical risk.

RESULTS

A total of 1720 pairs were analysed. During the study period, haemorrhage and ischaemia occurred in 25 (1·45%) and 67 participants (3·90%) in occasional users and 69 (4·01%) and 100 participants (5·81%) in regular users, whereas cancer occurred in 32 participants (1·86%) in occasional users and 26 participants (1·51%) in regular users. The crude and adjusted net clinical risks of low-dose aspirin use between the two frequency of users (≥ 80% vs. < 20%) were 4·12% (95% CI = 2·19%, 6·07%; P < 0·001) and 3·93% (95% CI = 2·01%, 5·84%; P < 0·001).

CONCLUSIONS

A long-term regular use of low-dose aspirin might not be better than occasional use in the primary prevention against major vascular diseases and cancer.

Updates on Nutraceutical Sleep Therapeutics and Investigational Research

Approximately 50% of the population will suffer from a sleep disorder over the course of their lifetime. There is increasing interest in nutraceuticals for these conditions. The quality of the evidence for the safety and effectiveness of using these supplements to treat sleep disorders varies substantially. In this review, we discuss the data about the effectiveness and safety of six commonly used plant-based sleep therapeutics: caffeine, chamomile, cherries, kava kava, L-tryptophan, marijuana, and valerian. We explore both historical uses of each substance and the current state of the literature.

A short-term effect of low-dose aspirin on major hemorrhagic risks in primary prevention: a case-crossover design

BACKGROUND

Very few studies have examined the risk of short-term adverse hemorrhage of low-dose aspirin use in primary prevention. This case-crossover study examined the transient effect of low-dose aspirin use on major hemorrhagic risks.

METHODS

A representative database of 1,000,000 patients randomly sampled from the Taiwan's National Health Insurance Research Database in 2000 was analyzed. The study cohort consisted of a total of 501,946 individuals, aged 30-95 years old, at risk of a major bleeding event in 2000. A case-crossover study was used to retrieve data on 10,905 incident patients with major hemorrhagic complications (3,781 cerebral and 7,124 gastrointestinal) and prescribed low-dose aspirin (≤300 mg/day) from 2000-2008. A 56-day time window (∼2 months) was used as the case period for which the odds ratio (OR) was estimated using the ratio of patients exposed during the 56-day case period only (1-56 days before the index date) compared to its corresponding 56-day control period only (57-112 days before the index date).

RESULTS

Four hundred eighty-nine (4.5%) of the 10,905 hemorrhagic patients had used low-dose aspirin during the 56-day case only period; 294 (2.7%) of the same patients had used low-dose aspirin during control only period. Low-dose aspirin use increase the risk of developing a major hemorrhage 1.33-fold (95% CI = 1.13-1.55, P<0.0001). Significance was found prominent in 4,453 non-hypertensive and non-diabetic subjects (Adjusted odds ratio = 1.88, 95% CI = 1.21-2.91).

CONCLUSION

Transient low-dose aspirin use increases risk for major hemorrhagic events in Han Chinese.

Boron-containing compounds: chemico-biological properties and expanding medicinal potential in prevention, diagnosis and therapy

INTRODUCTION

Although the medicinal use of boron-containing compounds (BCCs) had long been limited to antiseptics, in the last few decades, these compounds have been used as antibiotics or chemotherapeutic agents. In the last few years, boron has been included in the moieties of many known drugs to improve their capacity in binding to their respective target receptors.

AREAS COVERED

The current review focuses on research and patent literature of the last decade related to the development of BCCs as preventive, diagnostic and therapeutic tools. It explores the possible mechanisms of action of these compounds as well as the advantageous features of their structure and chemico-pharmacological properties.

EXPERT OPINION

Although uncertainties exist about the mechanism of action of BCCs, increasing evidence about their toxicological profile strongly suggests that many can be safely administered to humans. Even stronger evidence exists regarding the capacity of BCCs to reach multiple targets that are involved in the treatment of common diseases. It seems fair to say that some BCCs will reach the market for medicinal use in the near future, not only for targeting microbial or neoplastic systems but also for acting on cell-signaling processes involved in many other disorders.