Laboratory monitoring of patients treated with antihypertensive drugs and newly exposed to non steroidal anti-inflammatory drugs: a cohort study

NSAID: Current limits to prescription

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed to alleviate pain and inflammation in conditions like arthritis, migraines, and post-operative recovery. Their mechanism involves inhibiting prostaglandins that contribute to inflammation. NSAIDs are categorized based on their structure, selectivity for COX-1 and COX-2 enzymes, and plasma half-life. They are effective in treating osteoarthritis, spondyloarthritis, and rheumatoid arthritis but might carry an elevated risk of adverse events. Despite their effectiveness, NSAIDs have limitations and risks that warrant cautious consideration. Extensive research has investigated their side effects, and this review aims to examine the current limitations of oral NSAID therapy, including safety profiles, specific scenarios where their use may not be appropriate, and gaps in knowledge. By critically evaluating these aspects, healthcare practitioners can make informed decisions about prescribing NSAIDs, optimizing patient outcomes while minimizing potential risks. This narrative review summarizes existing knowledge and underscores the importance of risk-benefit assessments in NSAID prescribing. Ultimately, the goal is to enhance the rational use of NSAIDs, maximizing benefits while mitigating adverse effects.

Prevalence of Drug Interaction in Severely Obese Individuals and Associated Factors: Baseline Results from a Clinical Trial

The prevalence of obesity is increasing worldwide and is commonly associated with comorbidities. The use of several drugs is often necessary, which leads to Potential Drug Interactions (PDI) that may increase the morbidity and mortality. This study aimed to analyze the prevalence of drug interaction and its association with socio-demographics, health status, and drug use in severely obese individuals. Baseline data from a randomized clinical trial registered at Clinicaltrial.gov (NCT02463435) were used. A total of 150 individuals aged 18–65 years with a body mass index of 35 kg/m2 were included. The outcome variable was the presence of PDI, and the explanatory variables were divided into the following four levels: socio-demographic, lifestyle, health, and medication use. The prevalence of PDI was 50% (n = 75) (95% CI 41–58). The variables associated with drug–drug interactions in the multiple analyses were arterial hypertension (PR 1.83, 95%, CI 1.10–3.04), polypharmacy (PR 3.12, 95%, CI 2.17–4.50), and diabetes mellitus (PR 0.60, 95%, CI 0.45–0.81). The risk factors for the occurrence of drug interaction were the presence of diabetes mellitus, hypertension, and polypharmacy.

Machine Learning for Identifying Medication-Associated Acute Kidney Injury

One of the prominent problems in clinical medicine is medication-induced acute kidney injury (AKI). Avoiding this problem can prevent patient harm and reduce healthcare expenditures. Several researches have been conducted to identify AKI-associated medications using statistical, data mining, and machine learning techniques. However, these studies are limited to assessing the impact of known nephrotoxic medications and do not comprehensively explore the relationship between medication combinations and AKI. In this paper, we present a population-based retrospective cohort study that employs automated data analysis techniques to identify medications and medication combinations that are associated with a higher risk of AKI. By integrating multivariable logistic regression, frequent itemset mining, and stratified analysis, this study is designed to explore the complex relationships between medications and AKI in such a way that has never been attempted before. Through an analysis of prescription records of one million older patients stored in the healthcare administrative dataset at ICES (an independent, non-profit, world-leading research organization that uses population-based health and social data to produce knowledge on a broad range of healthcare issues), we identified 55 AKI-associated medications among 595 distinct medications and 78 AKI-associated medication combinations among 7748 frequent medication combinations. In addition, through a stratified analysis, we identified 37 cases where a particular medication was associated with increasing the risk of AKI when used with another medication. We have shown that our results are consistent with previous studies through consultation with a nephrologist and an electronic literature search. This research demonstrates how automated analysis techniques can be used to accomplish data-driven tasks using massive clinical datasets.

[Treatment of rheumatic disease with renal insufficiency]

BACKGROUND

Reduced renal function is not rare in patients with inflammatory rheumatic diseases and is associated with an increased risk of treatment-induced and perioperative adverse events.

METHOD

A literature search was carried out for the medical treatment and perioperative management of rheumatic disease in the presence of renal insufficiency.

RESULTS

Patients with rheumatic disease and renal insufficiency have a higher risk of cardiovascular disease, bone loss and immunodeficiency than those without kidney disease. The perioperative rate of cardiovascular and infectious complications and the risk of acute kidney failure are elevated in these patients. The pharmacokinetics of many drugs used in rheumatology is influenced by the kidney function. Especially methotrexate is contraindicated in patients with an estimated glomerular filtration rate (eGFR) <45 ml/min. Nonsteroidal anti-inflammatory drugs (NSAIDS) and cyclooxygenase (COX)-2 inhibitors should not be used with renal insufficiency or only for a short term with the lowest effective dose. The treatment of osteoporosis with antiresorptive drugs may lead to adynamic bone disease in advanced kidney disease, and, therefore, the use of these drugs is controversial.

CONCLUSION

Medication should be modified in patients with rheumatic disease and kidney involvement according the grade of renal insufficiency. There is also a need for special perioperative management in these patients, with interdisciplinary cooperation of rheumatologists, nephrologists and orthopedic doctors.

Methods in pharmacoepidemiology

Pharmacoepidemiology is the study of interactions between drugs and human populations, investigating, in real conditions of life, benefits, risks and use of drugs. Pharmacoepidemiology applies to drugs and their pharmacological evaluations, the different methods also used in epidemiology to assess in real conditions of life, benefits, risks and use of drugs. Pharmacoepidemiologic studies are ad-hoc studies or studies on databases. Specific methods exist to measure drug exposure, as well as indicators of compliance and misuse of drugs. Various designs for descriptive and explanatory studies exist, in a context in which a growing proportion of studies are carried out using medico-administrative data. The limits traditionally affecting the study designs are modified in this context, almost any design selected for the conduct of a study from these databases then deriving from a cohort in whom the information has been recorded prospectively and exhaustively.

Rationale and Design of a Randomized Placebo-Controlled Clinical Trial Assessing the Renoprotective Effects of Potassium Supplementation in Chronic Kidney Disease

BACKGROUND/AIMS

Dietary potassium (K+) has beneficial effects on blood pressure and cardiovascular (CV) outcomes. Recently, several epidemiological studies have revealed an association between urinary K+ excretion (as proxy for dietary intake) and better renal outcomes in subjects with chronic kidney disease (CKD). To address causality, we designed the "K+ in CKD" study.

METHODS

The K+ in CKD study is a multicenter, randomized, double blind, placebo-controlled clinical trial aiming to include 399 patients with hypertension, CKD stage 3b or 4 (estimated glomerular filtration rate [eGFR] 15-44 mL/min/1.73 m2), and an average eGFR decline > 2 mL/min/1.73 m2/year. As safety measure, all included subjects will start with a 2-week open-label phase of 40 mmol potassium chloride daily. Patients who do not subsequently develop hyperkalemia (defined as serum K+ >5.5 mmol/L) will be randomized to receive potassium chloride, potassium citrate (both K+ 40 mmol/day), or placebo for 2 years. The primary end point is the difference in eGFR after 2 years of treatment. Secondary end points include other renal outcomes (> 30% decrease in eGFR, doubling of serum creatinine, end-stage renal disease, albuminuria), ambulatory blood pressure, CV events, all-cause mortality, and incidence of hyperkalemia. Several measurements will be performed to analyze the effects of potassium supplementation, including body composition monitoring, pulse wave velocity, plasma renin and aldosterone concentrations, urinary ammonium, and intracellular K+ concentrations.

CONCLUSION

The K+ in CKD study will demonstrate if K+ sup-plementation has a renoprotective effect in progressive CKD, and whether alkali therapy has additional beneficial effects.

Practical approach to detection and management of acute kidney injury in critically ill patient

Background

Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with high morbidity and mortality. This paper provides a critical review of the etiologies of AKI and a systematic approach toward its diagnosis and management with emphasis on fluid volume assessment and the use of urine biochemical profile and microscopy in identifying the nature and the site of kidney injury.

Materials and methods

The search of PubMed and selection of papers had employed observational designs or randomized control trials relevant to AKI.

Results

AKI is defined by the rate of rise of serum creatinine and a decline in urine output. The pathophysiology is diverse and requires a careful and systematic assessment of predisposing factors and localization of site of injury. The majority of AKIs are due to prerenal causes such as fluid volume deficit, sepsis, or renal as in acute tubular injury. The use of central venous and arterial blood pressure monitoring and inferior vena cava echocardiography complemented by urine analysis and microscopy allows assessment of fluid volume status and AKI etiology.

Conclusions

Timely intervention by avoidance of fluid volume deficit and nephrotoxic agents and blood pressure support can reduce the incidence of AKI in critically ill patients.

Elevated baseline potassium level within reference range is associated with worse clinical outcomes in hospitalised patients

The clinical significance of elevated baseline serum potassium (K⁺) levels in hospitalised patients is rarely described. Hence, we performed a retrospective study assessing the significance of elevated K⁺ levels in a one-year admission cohort. Adult patients without hypokalaemia or end-stage renal disease were included. Adverse outcomes were all-cause mortality, hospital-acquired acute kidney injury, and events of arrhythmia. In total, 17,777 patients were included in the study cohort, and a significant difference (P < 0.001) was observed in mortality according to baseline serum K⁺ levels. The adjusted hazard ratios (HRs) and associated 95% confidence intervals (CIs) of all-cause mortality for K⁺ levels above the reference range of 3.6–4.0 mmol/L were as follows: 4.1–4.5 mmol/L, adjusted HR 1.075 (95% CI 0.981–1.180); 4.6–5.0 mmol/L, adjusted HR 1.261 (1.105–1.439); 5.1–5.5 mmol/L, adjusted HR 1.310 (1.009–1.700); >5.5 mmol/L, adjusted HR 2.119 (1.532–2.930). Moreover, the risks of in-hospital acute kidney injury and arrhythmia were higher in patients with serum K⁺ levels above 4.0 mmol/L and 5.5 mmol/L, respectively. In conclusion, increased serum K⁺ levels, including mild elevations may be related to worse prognosis. Close monitoring and prompt correction of underlying causes or hyperkalaemia itself is warranted for admitted patients.

Drug Class Combination–Associated Acute Kidney Injury

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

Mechanisms of triple whammy acute kidney injury

Pre-renal acute kidney injury (AKI) results from glomerular haemodynamic alterations leading to reduced glomerular filtration rate (GFR) with no parenchymal compromise. Renin-angiotensin system inhibitors, such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor antagonists (ARAs), non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, are highly prescribed drugs that are frequently administered together. Double and triple associations have been correlated with increased pre-renal AKI incidence, termed "double whammy" and "triple whammy", respectively. This article presents an integrative analysis of the complex interplay among the effects of NSAIDs, ACEIs/ARAs and diuretics, acting alone and together in double and triple therapies. In addition, we explore how these drug combinations alter the equilibrium of regulatory mechanisms controlling blood pressure (renal perfusion pressure) and GFR to increase the odds of inducing AKI through the concomitant reduction of blood pressure and distortion of renal autoregulation. Using this knowledge, we propose a more general model of pre-renal AKI based on a multi whammy model, whereby several factors are necessary to effectively reduce net filtration. The triple whammy was the only model associated with pre-renal AKI accompanied by a course of other risk factors, among numerous potential combinations of clinical circumstances causing hypoperfusion in which renal autoregulation is not operative or is deregulated. These factors would uncouple the normal BP-GFR relationship, where lower GFR values are obtained at every BP value.

Adherence to renal function monitoring guidelines in patients starting antihypertensive therapy with diuretics and RAAS inhibitors: a retrospective cohort study

BACKGROUND

Acute kidney injury (AKI) might complicate antihypertensive therapy. In The Netherlands, general practitioner clinical practice guidelines provide clear recommendations on monitoring of renal function to minimize this risk. Our objective was to investigate how day-to-day clinical practice corresponds to the guidelines.

METHODS

We conducted a retrospective cohort study in a dynamic population, using data on >9,000 adults that was retrieved from the Integrated Primary Care Information database. We investigated whether serum creatinine (SCR) was measured within 30 and 365 days after the start of (combined) use of a diuretic, an angiotensin-converting enzyme inhibitor, and/or angiotensin receptor blocker. We also investigated the association between calendar year, sex, type of therapy, risk factors for AKI and practice and SCR measurement.

RESULTS

Of 6,593 subjects who met the study criteria for single drug therapy, SCR was measured in 1,233 subjects within 30 days and in 3,896 subjects within 365 days. For combined drug therapy recipients (n = 2,497), these were 545 and 1,687, respectively. Associated cumulative probabilities were 19 % and 66 % with single drug therapy, and 22 % and 74 % with combined drug therapy. Significant differences were observed between practices. SCR measurement was associated with other characteristics, except for sex. Within 365 days, SCR increased >30 % of baseline in 103 subjects (1.6 %) after the start of single drug therapy, and in 85 (3.4 %) subjects who initiated combined drug therapy. In the majority (>70 %) of these subjects, this did not result in subsequent monitoring or adjustment of antihypertensive treatment.

CONCLUSIONS

Results from this study suggest that, on average, renal function is not monitored as strictly as recommended by relevant clinical practice guidelines.

Drug interactions between antihypertensive drugs and non-steroidal anti-inflammatory agents: a descriptive study using the French Pharmacovigilance database

Drug-drug interactions (DDIs) between antihypertensive drugs and non-steroidal anti-inflammatory drugs (NSAIDs) can lead to adverse drug reactions (ADRs). Guidelines are available to help prescribers deal with these drug associations, but their implementation is not well evaluated. The aims of this study were to assess the prevalence of NSAIDs exposure in patients treated with antihypertensive drugs, using the French Pharmacovigilance database, and explore the ADRs related to DDIs between antihypertensive drugs and NSAIDs. Over the 11, 442 notifications of ADRs recorded in this database in patients treated with oral antihypertensive drugs between 2008 and 2010, 517 (4.5 and 95% CI: 4.1-4.9) also included exposure to NSAIDs. These subjects were more frequently women, took more drugs in general, and were younger and less frequently treated with antiplatelet drugs. In 24.2% of them (125 patients), a DDI between NSAIDs and antihypertensive drugs was potentially the cause of the reported ADR. Acute renal failure caused by DDIs between NSAIDs and angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or diuretics was the most frequently reported ADR (20.7%). Finally, in the French Pharmacovigilance database, around one-fourth of associations NSAIDs  +  antihypertensive drugs are associated with a 'serious' ADR (mainly acute renal failure), suggesting that this well-known DDI is not enough taken into account by prescribers.