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Shahid F, Doherty A, Wallace E, Schmiedl S, Alexander GC, Dreischulte T. Prescribing cascades in ambulatory care: A structured synthesis of evidence. Pharmacotherapy 2024; 44:87-96. [PMID: 37743815 DOI: 10.1002/phar.2880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/04/2023] [Accepted: 06/23/2023] [Indexed: 09/26/2023]
Abstract
The strength of evidence for specific ambulatory care prescribing cascades, in which a marker drug is used to treat an adverse event caused by an index drug, has not been well characterized. To perform a structured, systematic, and transparent review of the evidence supporting ambulatory care prescribing cascades. Ninety-four potential prescribing cascades identified through a previously published systematic review. Systematic search of the literature to further characterize prescribing cascades. (1) Grading of evidence based on observational studies investigating associations between index and marker drugs, including: Level I-strong evidence [i.e. multiple high-quality studies]; Level II-moderate evidence [i.e. single high-quality study]; Level III-fair evidence [no high-quality studies but one or more moderate-quality studies]; and Level IV-poor evidence [other]. (2) Listing of the adverse event associated with the index drug in the product's United States Food and Drug Administration (FDA) label. (3) Synthesis of the evidence supporting mechanisms linking index drugs and associated adverse events. Of 99 potential cascades, 94 were supported by one or more confirmatory observational studies and were therefore included in this review. The 94 cascades related to 30 types of adverse drug reactions affecting 10 different anatomic/physiologic systems and were investigated by a total of 88 confirmatory studies, including prescription sequential symmetry analysis (n = 51), cohort (n = 30), and case-control (n = 7) studies. Overall, the evidence from observational studies was strong for 18 (19.1%) prescribing cascades, moderate for 61 (64.9%), fair for 13 (13.8%), and poor for 2 (2.1%). Although the evidence supporting mechanisms that link index drugs and associated adverse events was variable, FDA labels included information about the adverse event associated with the index drug for most (n = 86) but not all of the 94 prescribing cascades. Although we identified 18 of 94 prescribing cascades supported by strong clinical evidence and most adverse events associated with index drugs are included in FDA label, the evidentiary basis for prescribing cascades varies, with many requiring further evidence of clinical relevance.
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Affiliation(s)
- Faiza Shahid
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Ann Doherty
- Department of General Practice, University College Cork, Cork, Ireland
| | - Emma Wallace
- Department of General Practice, University College Cork, Cork, Ireland
| | - Sven Schmiedl
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - G Caleb Alexander
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
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Adrien O, Mohammad AK, Hugtenburg JG, McCarthy LM, Priester-Vink S, Visscher R, van den Bemt PMLA, Denig P, Karapinar-Carkıt F. Prescribing Cascades with Recommendations to Prevent or Reverse Them: A Systematic Review. Drugs Aging 2023; 40:1085-1100. [PMID: 37863868 PMCID: PMC10682291 DOI: 10.1007/s40266-023-01072-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND To reduce prescribing cascades occurring in clinical practice, healthcare providers require information on the prescribing cascades they can recognize and prevent. OBJECTIVE This systematic review aims to provide an overview of prescribing cascades, including dose-dependency information and recommendations that healthcare providers can use to prevent or reverse them. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Relevant literature was identified through searches in OVID MEDLINE, OVID Embase, OVID CINAHL, and Cochrane. Additionally, Web of Science and Scopus were consulted to analyze reference lists and citations. Publications in English were included if they analyzed the occurrence of prescribing cascades. Prescribing cascades were included if at least one study demonstrated a significant association and were excluded when the adverse drug reaction could not be confirmed in the Summary of Product Characteristics. Two reviewers independently extracted and grouped similar prescribing cascades. Descriptive summaries were provided regarding dose-dependency analyses and recommendations to prevent or reverse these prescribing cascades. RESULTS A total of 95 publications were included, resulting in 115 prescribing cascades with confirmed adverse drug reactions for which at least one significant association was found. For 52 of these prescribing cascades, information regarding dose dependency or recommendations to prevent or reverse prescribing cascades was found. Dose dependency was analyzed and confirmed for 12 prescribing cascades. For example, antipsychotics that may cause extrapyramidal syndrome followed by anti-parkinson drugs. Recommendations focused on dosage lowering, discontinuing medication, and medication switching. Explicit recommendations regarding alternative options were given for three prescribing cascades. One example was switching to ondansetron or granisetron when extrapyramidal syndrome is experienced using metoclopramide. CONCLUSIONS In total, 115 prescribing cascades were identified and an overview of 52 of them was generated for which recommendations to prevent or reverse them were provided. Nonetheless, information regarding alternative options for managing prescribing cascades was scarce.
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Affiliation(s)
- Oriane Adrien
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Atiya K Mohammad
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jacqueline G Hugtenburg
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - Lisa M McCarthy
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Leslie Dan Faculty of Pharmacy and Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Robbert Visscher
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Fatma Karapinar-Carkıt
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands.
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, The Netherlands.
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Alqahtani SS, Alabeedi FM. Association of oral candidiasis with oral lichen planus in patients using corticosteroid therapy - Meta-analysis. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY = JOURNAL DE LA THERAPEUTIQUE DES POPULATIONS ET DE LA PHARMACOLOGIE CLINIQUE 2023; 30:e1-e13. [PMID: 36631413 DOI: 10.47750/jptcp.2023.1020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 01/13/2023]
Abstract
Oral lichen planus (OLP) is a chronic inflammatory disease that commonly affects the skin and mucous membranes. There is a difference of opinion among clinicians about whether OLP has been associated with oral candidiasis. Nonetheless, in OLP patients, the oral candidiasis prevalence rate ranges from 7.7 to 16.6%, as established through biopsy findings, whereas 37-50% of the prevalence rate has been noticed in culture findings. Oral candidiasis has been linked to several local and systemic factors, including salivary gland dysfunction, dental prostheses, topical or inhaled corticosteroids, smoking, and the use of systemic medications. The aim was to highlight the association of Candida in patients diagnosed with OLP, correlate the use of steroid therapy, and enumerate the factors of using steroid therapy as implicated causes for oral candidiasis. A search was made using search engines such as PubMed, Scopus, Cochrane Database of Systematic Reviews, Science Citation Index, NIH Public Access, and Clarivate Analytics (Figure 1). The keywords using the research option for this field were "Oral Candidiasis" AND "Oral Lichen planus" or "Candidiasis" AND "Corticosteroids" or "Topical Corticosteroids" AND Oral Lichen planus or "Inhalation Corticosteroids" AND "Candidiasis" or "Oral Lichen planus" AND "Corticosteroids." The database search was made for the duration of 1991 to -2021 (Table 1). Additional articles were obtained regarding the literature on OLP and oral candidiasis and were considered background material. The incidence of oral candidiasis and associated lichen planus following steroid therapy enlisted by various authors has been addressed. According to the results of this study, there is a positive correlation between the presence of oral candidiasis in the OLP's patients treated with corticosteroids. Finally, this meta-analysis concluded that there is a positive correlation between the presence of Candida species in OLP and steroid medication.
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Affiliation(s)
- Sulaiman S Alqahtani
- Department of Oral & Maxillofacial Surgery and Diagnostic Sciences, Faculty of Dentistry, Najran University, Najran, Saudi Araxbia.;
| | - Faris M Alabeedi
- Department of Oral & Maxillofacial Surgery and Diagnostic Sciences, Faculty of Dentistry, Najran University, Najran, Saudi Araxbia
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Muacevic A, Adler JR, Schrepfer T. Postoperative Pain Exacerbation After Adenotonsillectomy Due to Oral Candida Infection? Cureus 2022; 14:e32115. [PMID: 36601179 PMCID: PMC9805389 DOI: 10.7759/cureus.32115] [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] [Accepted: 11/30/2022] [Indexed: 12/04/2022] Open
Abstract
Post-tonsillectomy complications can include bleeding, dehydration, edema, airway obstruction, and infection. Oral candidiasis or thrush is a rare complication that can occur post-operatively. We describe a case of a 10-year-old female with oral candidiasis as a postoperative complication of bilateral adenotonsillectomy, presenting on postoperative day (POD) 7 for poor oral intake secondary to worsening odynophagia. A physical exam revealed an easily scrapable, white plaque located mainly over her surgical sites, tongue, and hard palate. Microscopic examination of tissue scrapings revealed pseudohyphae confirming the diagnosis of oral candidiasis. She was treated with seven days of topical nystatin therapy, including topical and systemic pain control with significant improvement of symptoms by POD 13 and complete resolution on POD 21.
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Dreischulte T, Shahid F, Muth C, Schmiedl S, Emil Haefeli W. Prescribing Cascades: How to Detect Them, Prevent Them, and Use Them Appropriately. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:745-752. [PMID: 36045504 PMCID: PMC9853235 DOI: 10.3238/arztebl.m2022.0306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/02/2022] [Accepted: 08/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND A prescribing cascade is the treatment of an adverse drug reaction (ADR) with another drug. In this review, we discuss (a) the different types of prescribing cascade and (b) the measures that can be taken so that they will be recognized and dealt with appropriately, both in the hospital and in the outpatient setting. METHODS This review is based on pertinent publications retrieved by a selective literature search. RESULTS The literature distinguishes intentional from unintentional prescribing cascades, and appropriate from inappropriate ones. We further distinguish prophylactic from therapeutic prescribing cascades and draw a line between those that are necessary and those that are merely appropriate. The following main questions are essential for dealing with prescribing cascades appropriately: (1) Did the precipitating drug cause a clinically relevant ADR or risk of an ADR? (2) Is the precipitating drug still indicated? (3) Can an ADR be avoided by altering the treatment with the precipitating drug, or by (4) switching to another drug instead? (5) Can the drug used to treat the ADR actually affect it beneficially? (6) Do the benefits of the prescribing cascade outweigh its risks? CONCLUSION Prescribing cascades are not problematic in themselves; on the contrary, they are sometimes a necessary part of good prescribing practice. There is still a lack of practically implementable instruments to help physicians detect prescribing cascades reliably, assess them properly, and put them to appropriate use.
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Affiliation(s)
- Tobias Dreischulte
- *These authors share first authorship.,Institute of General Practice and Family Medicine, University Hospital of Ludwig-Maximilians-University Munich,*Institut für Allgemeinmedizin Klinikum der Ludwig-Maximilians-Universität München Campus Innenstadt Pettenkoferstraße 10 80336 München
| | - Faiza Shahid
- *These authors share first authorship.,Institute of General Practice and Family Medicine, University Hospital of Ludwig-Maximilians-University Munich
| | - Christiane Muth
- Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld
| | - Sven Schmiedl
- Philipp Klee-of Clinical Pharmacology, Helios Clinic Wuppertal; Clinical Pharmacology, Witten/Herdecke University, Witten/Herdecke
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelbergg
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Doherty AS, Shahid F, Moriarty F, Boland F, Clyne B, Dreischulte T, Fahey T, Kennelly SP, Wallace E. Prescribing cascades in community-dwelling adults: A systematic review. Pharmacol Res Perspect 2022; 10:e01008. [PMID: 36123967 PMCID: PMC9485823 DOI: 10.1002/prp2.1008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/15/2022] Open
Abstract
The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. A systematic review was reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline [Ovid], EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: community-dwelling adults; risk-prescription medication; outcomes-initiation of new medicine to "treat" or reduce ADR risk; study type-cohort, cross-sectional, case-control, and case-series studies. Title/abstract screening, full-text screening, data extraction, and methodological quality assessment were conducted independently in duplicate. A narrative synthesis was conducted. A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11 593 989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n = 5), amiodarone to levothyroxine (n = 5), inhaled corticosteroid to topical antifungal (n = 4), antipsychotic to anti-Parkinson drug (n = 4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n = 4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months.
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Affiliation(s)
- Ann S. Doherty
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Faiza Shahid
- Institute of General Practice and Family MedicineUniversity Hospital of Ludwig‐Maximilians‐University MunichMunichGermany
| | - Frank Moriarty
- School of Pharmacy and Biomolecular SciencesRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Fiona Boland
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
- Data Science CentreRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Barbara Clyne
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Tobias Dreischulte
- Institute of General Practice and Family MedicineUniversity Hospital of Ludwig‐Maximilians‐University MunichMunichGermany
| | - Tom Fahey
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Seán P. Kennelly
- Department of Medical GerontologyTrinity College DublinDublin 2Ireland
- Department of Age‐related HealthcareTallaght University HospitalDublin 24Ireland
| | - Emma Wallace
- Department of General PracticeUniversity College CorkCorkIreland
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Xiao JL, Xu GC, de Hoog S, Qiao JJ, Fang H, Li YL. Oral Prevalence of Candida Species in Patients Undergoing Systemic Glucocorticoid Therapy and the Antifungal Sensitivity of the Isolates. Infect Drug Resist 2020; 13:2601-2607. [PMID: 32801797 PMCID: PMC7405946 DOI: 10.2147/idr.s262311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/16/2020] [Indexed: 11/25/2022] Open
Abstract
Background Candida species are commonly detected as colonizers of the oral cavity; candidiasis or candidemia can develop in patients who are immunocompromised. Use of topical or inhaled glucocorticoids can alter the spectrum of Candida species and can promote oral candidiasis. The present study aims to evaluate the diversity of Candida species in the oral cavity and their susceptibility to antifungal agents in patients undergoing treatment with systemic glucocorticoids (SGCs) compared with non-users. Methods We conducted a descriptive, analytical, cross-sectional study that enrolled 120 patients with oral problems who were undergoing treatment with SGCs and who were admitted to the hospital of the First Affiliated Hospital, College of Medicine, Zhejiang University and Zhejiang Hospital, Hangzhou, China, between February 2019 and September 2019. One hundred and twenty age-and sex-matched patients were recruited as the SGC non-user control group. Demographic data included oral complaints and underlying diseases; symptoms of oral candidiasis were identified on physical examination. Candida species were collected using a concentrated oral rinse. Identification of fungal isolates was based on conventional phenotypic methods assisted by DNA sequence analysis of the internal transcribed spacer (ITS) rDNA gene region. Antifungal activities of anidulafungin, amphotericin B, micafungin, caspofungin, 5-flucytosine, posaconazole, voriconazole, itraconazole, and fluconazole were evaluated using the Sensititre YeastOneTM YO10 panel supplemented by the CLSI-M27-A3 protocol. Results Fifty-two (43.33%) out of the 120 patients undergoing with SGCs were diagnosed with oral candidiasis, compared with 14 (11.67%) of the non-users (P < 0.05). Likewise, we collected 88 strains from 73.33% of the SGC users compared with only 48 (40%) from non-users (P < 0.05). Candida albicans was detected most frequently in both groups (45.45% vs 66.67%, respectively; P = 0.033); the overall frequency of non-Candida albicans (NCA) strains isolated from patients treated with SGCs were significantly higher than that identified among non-users (51.14% vs 33.33%, respectively; P = 0.046), although there were no significant differences concerning any single species of NCA. Resistance of C. albicans to itraconazole (P = 0.004) and fluconazole (P = 0.001) was significantly higher in patients treated with SGCs than in non-users; however, echinocandins, amphotericin B, voriconazole, and posaconazole were all active against strains from both participant groups with no significant differences detected. Conclusion Taken together, our findings indicate that SGC therapy may result in an increased prevalence of oral candidiasis as reflected by the clinical presentations and strains isolated; these findings were also associated with an increased frequency of NCA strains. SGC therapy was also associated with an increased frequency of C. albicans strains that were resistant to both itraconazole and fluconazole. The impact of SGC therapy on Candida species in the oral cavity requires further study.
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Affiliation(s)
- Jia-Ling Xiao
- Department of Stomatology, Zhejiang Hospital, Hangzhou, Zhejiang Province, People's Republic of China
| | - Guo-Chao Xu
- Department of Stomatology, Zhejiang Hospital, Hangzhou, Zhejiang Province, People's Republic of China
| | - Sybren de Hoog
- Center of Expertise in Mycology of Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jian-Jun Qiao
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Ya-Li Li
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of the published studies that have been used to generate evidence on the safety of medicine use when only medication dispensing data are available. RECENT FINDINGS Medication dispensing databases are increasingly available for research on large populations, particularly in countries that provide universal coverage for medicines. These data are often used for drug utilisation studies to identify inappropriate medicine use at the population level that may be associated with known safety issues. Lack of coded diagnoses, to identify outcomes, and lack of data on confounders can limit use of these data in practice for medication safety assessment. To overcome these issues, studies have exploited the fact that symptoms of adverse effects of medications can be treated with other medications, for example antidepressants to treat depression or oxybutynin to treat urinary incontinence. The challenge of unmeasured confounding has been addressed by implementing self-controlled study designs that use within-person comparisons and provide inherent control for confounding. Prescription sequence symmetry analysis (SSA) is a within-person study design that has been demonstrated as a useful tool for safety signal generation in dispensing data. SUMMARY Using medicine initiation as a proxy for the development of adverse events can help to generate evidence of the safety of medicines when only medication dispensing data are available. Careful consideration, however, should be given to the sensitivity and specificity of the proxy medicine for the adverse event and potential for time-varying confounding due to trends in medicine utilisation. Data-mining approaches using dispensing data have the potential to improve safety assessments; however, the challenge of unmeasured confounding with these methods remains to be investigated.
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Affiliation(s)
- Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia
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Winkel JS, Damkier P, Hallas J, Henriksen DP. Treatment with montelukast and antidepressive medication-a symmetry analysis. Pharmacoepidemiol Drug Saf 2018; 27:1409-1415. [PMID: 30136330 DOI: 10.1002/pds.4638] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/26/2018] [Accepted: 07/17/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Leukotriene receptor antagonists are used in asthma and rhinitis treatment. Pharmacovigilance data have suggested an association between montelukast and depression, but the association has not been established in controlled study designs. We described the association between initiation of montelukast and depression, using prescriptions of antidepressants as a surrogate marker, and assessed whether the association was related to the underlying asthma disease. METHODS We performed a symmetry analysis, with a study period from January 1, 2000 to December 31, 2016, using 3 nationwide Danish registers. We included all adults, who filled their first prescription of montelukast and antidepressants within an interval of 1 year. In the absence of an association between montelukast and antidepressant use, a symmetrical distribution of prescriptions is expected before and after montelukast initiation (ie, a sequence ratio [rc ] of 1.0). We subcategorized the subjects after the severity of underlying asthma disease. RESULTS In total, 4450 subjects filled their first prescriptions of both montelukast and antidepressants within a 1-year interval: 2434 redeemed their first prescription of montelukast before antidepressants, and 2016 redeemed the medications in the opposite order (rc 1.21 [95% CI 1.14-1.28]). We found rc above unity in groups with long-acting asthma treatment, but no increase in antidepressant prescription, when stratifying by the asthma severity. CONCLUSION We found a weak association between the use of montelukast and the risk of being prescribed an antidepressant, unlikely to be of clinical relevance. Stratified analyses suggest that this association may relate to asthma, rather than to montelukast.
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Affiliation(s)
- Jane Sterndorff Winkel
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Daniel Pilsgaard Henriksen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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