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Fleming VH, Xu J, Chen X, Hall D, Southwood RL. Risk of Tendon Injury in Patients Treated With Fluoroquinolone (FQ) Versus Non-Fluoroquinolone Antibiotics for Community-Acquired Pneumonia (CAP). Ann Pharmacother 2024; 58:771-780. [PMID: 37946374 DOI: 10.1177/10600280231210275] [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] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Fluoroquinolones (FQs) are associated with increased risk of tendon injury but comparative risk versus other antibiotic options for the same indication has yet to be evaluated. OBJECTIVE Describe the incidence (relative risk) of any tendon injury in patients receiving FQ compared with other (non-FQs) antibiotics for treatment of community-acquired pneumonia (CAP). METHODS A retrospective propensity score weighted cohort study was performed to evaluate the association between FQ antibiotics and tendon injury risk at 2 time points (within 1 month and within 6 months of use) compared with non-FQ regimens for treatment of CAP. The evaluation was performed using the CCAE (MarketScan Commercial Claims and Encounters) and COB (Medicare Supplemental and Coordination of Benefits) databases from 2014 to 2020. Patients with ICD (International Classification of Diseases) 9/10 coding for outpatient pneumonia who were >18 years and without history of tendon injury were included. Patients with history of tendon injury, who received multiple antibiotic therapies for recurrent pneumonia, or who received both FQ and non-FQ regimens during the study period were excluded. Propensity score weighting was used to adjust for selection bias due to contributing risk factors, including demographics (age, sex), comorbidities (diabetes mellitus, chronic kidney disease), and concurrent medications (corticosteroids). RESULTS At 1 month, the odds of tendon injury were estimated to be significantly higher (41.9%) in patients receiving FQs compared with those receiving a non-FQ-based regimen (odds ratio [OR] = 1.419, 95% confidence interval [CI] = [1.188-1.698]). The odds of tendon injury were also estimated to be higher (OR = 1.067, 95% CI = [0.975-1.173]) in the FQ population within 180 days, but this effect was not statistically significant. The most frequent sites of tendon injuries were rotator cuff, shoulder, and patellar tendon. CONCLUSIONS AND RELEVANCE Prescribers should recognize the risk of tendon injury within 1 month of FQ use when considering treatment regimens for CAP and use alternative options with lower risk whenever possible.
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Affiliation(s)
| | - Jianing Xu
- Department of Statistics, University of Georgia, Athens, GA, USA
| | - Xianyan Chen
- Department of Statistics, University of Georgia, Athens, GA, USA
| | - Daniel Hall
- Department of Statistics, University of Georgia, Athens, GA, USA
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Meesters K, Balbas-Martinez V, Allegaert K, Downes KJ, Michelet R. Personalized Dosing of Medicines for Children: A Primer on Pediatric Pharmacometrics for Clinicians. Paediatr Drugs 2024; 26:365-379. [PMID: 38755515 DOI: 10.1007/s40272-024-00633-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/18/2024]
Abstract
The widespread use of drugs for unapproved purposes remains common in children, primarily attributable to practical, ethical, and financial constraints associated with pediatric drug research. Pharmacometrics, the scientific discipline that involves the application of mathematical models to understand and quantify drug effects, holds promise in advancing pediatric pharmacotherapy by expediting drug development, extending applications, and personalizing dosing. In this review, we delineate the principles of pharmacometrics, and explore its clinical applications and prospects. The fundamental aspect of any pharmacometric analysis lies in the selection of appropriate methods for quantifying pharmacokinetics and pharmacodynamics. Population pharmacokinetic modeling is a data-driven method ('top-down' approach) to approximate population-level pharmacokinetic parameters, while identifying factors contributing to inter-individual variability. Model-informed precision dosing is increasingly used to leverage population pharmacokinetic models and patient data, to formulate individualized dosing recommendations. Physiologically based pharmacokinetic models integrate physicochemical drug properties with biological parameters ('bottom-up approach'), and is particularly valuable in situations with limited clinical data, such as early drug development, assessing drug-drug interactions, or adapting dosing for patients with specific comorbidities. The effective implementation of these complex models hinges on strong collaboration between clinicians and pharmacometricians, given the pivotal role of data availability. Promising advancements aimed at improving data availability encompass innovative techniques such as opportunistic sampling, minimally invasive sampling approaches, microdialysis, and in vitro investigations. Additionally, ongoing research efforts to enhance measurement instruments for evaluating pharmacodynamics responses, including biomarkers and clinical scoring systems, are expected to significantly bolster our capacity to understand drug effects in children.
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Affiliation(s)
- Kevin Meesters
- Department of Pediatrics, University of British Columbia, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada.
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada.
| | | | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Kevin J Downes
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
- qPharmetra LLC, Berlin, Germany
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Brinkman JC, Reeson E, Chhabra A. Acute Patellar Tendon Ruptures: An Update on Management. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00011. [PMID: 38569093 PMCID: PMC10994452 DOI: 10.5435/jaaosglobal-d-24-00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 04/05/2024]
Abstract
Patellar tendon ruptures can be debilitating injuries. When incomplete, partial tears can be managed nonsurgically with immobilization and progressive rehabilitation. Although complete ruptures remain a relatively uncommon injury, they portend a high level of morbidity. Ruptures typically result from an acute mechanical overload to the extensor mechanism, such as with forced quadriceps contraction and knee flexion. However, chronically degenerated tendons are also predisposed to failure from low-energy injuries. Diagnosis can often be made clinically with recognition of a palpable defect to the tendon, localized patellar tendon tenderness, and inability to actively extend the knee. Diagnosis and surgical planning can be established with radiograph, ultrasonography, or magnetic resonance imaging. Surgical repair is the mainstay of treatment, and there have been many recent advances in repair technique, optimal reconstruction strategies, and supplemental fixation. Time to surgery for complete tears remains the most important prognosticator for success. Direct primary repair can be completed with transosseous tunnels, suture anchor repair, or end-to-end repair. Tendon reconstruction can be achieved with or without mechanical or biologic augments. Rehabilitation programs vary in specifics, but return to sport can be expected by 6 months postoperatively.
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Affiliation(s)
- Joseph C. Brinkman
- From the Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ (Dr. Brinkman, Dr. Chhabra), and the Crieghton University School of Medicine, Phoenix, AZ (Ms. Reeson)
| | - Emily Reeson
- From the Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ (Dr. Brinkman, Dr. Chhabra), and the Crieghton University School of Medicine, Phoenix, AZ (Ms. Reeson)
| | - Anikar Chhabra
- From the Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ (Dr. Brinkman, Dr. Chhabra), and the Crieghton University School of Medicine, Phoenix, AZ (Ms. Reeson)
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Tran PT, Antonelli PJ, Winterstein AG. Quinolone Ear Drops and Achilles Tendon Rupture. Clin Infect Dis 2023; 76:e1360-e1368. [PMID: 36065683 DOI: 10.1093/cid/ciac709] [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: 05/24/2022] [Revised: 08/15/2022] [Accepted: 08/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delayed eardrum healing has been observed in the ear opposite to the ear treated with otic quinolones (OQ) in rats. Case reports describe tendinopathies after OQ treatment, suggesting adverse systemic effects. METHODS We studied patients aged 19 to 64 years with diagnosis of otitis externa or media in private insurance between 2005 and 2015. We compared OQ treatment against otic neomycin, oral amoxicillin, or azithromycin. Outcomes included Achilles tendon rupture (ATR), Achilles tendinitis (AT), and all-type tendon rupture (ATTR). We applied an active comparator, new-user design with 1-year look-back and ceased follow-up at initiation of systemic steroids or oral quinolones, external injury, hospitalization, and after 35 days. We used trimmed stabilized inverse probability of treatment weights to balance comparison groups in a survival framework. Negative outcomes (clavicle fractures or sports injuries) were examined to rule out differences from varied physical activity (unmeasured confounding). RESULTS We examined 1 501 009 treated otitis episodes. Hazard ratios (HR) for OQ exposure associated with ATR were 4.49 (95% confidence interval [CI], 1.83-11.02), AT 1.04 (95% CI, 0.73-1.50), and ATTR 1.71 (95% CI, 1.21-2.41). Weighted risk differences (RD) per 100 000 episodes for OQ exposure were ATR 7.80 (95% CI, 0.72-14.89), AT 1.01 (95% CI, -12.80 to 14.81), and ATTR 18.57 (95% CI, 3.60-33.53). Corresponding HRs for clavicle fractures and sports injuries were HR,1.71 (95% CI, 0.55-5.27) and HR,1.45 (95% CI, 0.64-3.30), suggesting limited residual confounding. CONCLUSIONS OQ exposure may lead to systemic consequences. Clinicians should consider this potential risk and counsel patients accordingly. Risk factors and mechanisms for this rare, adverse effect deserve further evaluation. Mechanistic and other clinical studies are warranted to corroborate this finding.
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Affiliation(s)
- Phuong T Tran
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Faculty of Pharmacy, HUTECH University, Ho Chi Minh City, Vietnam
| | - Patrick J Antonelli
- College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA.,Department of Otolaryngology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA.,Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
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El Feghaly RE, Goldman JL. Perceived Harm May Be Helpful: Fear of Fluoroquinolone-Associated Adverse Events in Children. Pediatrics 2021; 147:peds.2021-050321. [PMID: 33990460 DOI: 10.1542/peds.2021-050321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Rana E El Feghaly
- Children's Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri
| | - Jennifer L Goldman
- Children's Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri
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Abstract
Appropriate prescribing practices for fluoroquinolones, as well as all antimicrobial agents, are essential as evolving resistance patterns are considered, additional treatment indications are identified, and the toxicity profile of fluoroquinolones in children has become better defined. Earlier recommendations for systemic therapy remain; expanded uses of fluoroquinolones for the treatment of certain infections are outlined in this report. Prescribing clinicians should be aware of specific adverse reactions associated with fluoroquinolones, and their use in children should continue to be limited to the treatment of infections for which no safe and effective alternative exists or in situations in which oral fluoroquinolone treatment represents a reasonable alternative to parenteral antimicrobial therapy.
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