Agreement between medical record documentation and patient-reported use of nonsteroidal antiinflammatory drugs

Risk of Bleeding Among Individuals on Direct-Acting Oral Anticoagulants: An Academic Medical Center Cohort Study

ABSTRACT

Previous research has identified risk factors that may affect the risk of bleeding when individuals are exposed to oral anticoagulants. It is unclear if the risk continues to exist with the direct oral anticoagulants (DOACs). The purpose of this study was to assess the risk of bleeding in patients on DOACs (apixaban, rivaroxaban, dabigatran, edoxaban, and betrixaban) based on known risk factors including demographics, medical conditions, and concomitant medications. This study was a retrospective analysis using electronic health record data from the University of Utah Hospital (Division of Cardiovascular Medicine) of individuals receiving a DOAC from 2015 to 2020. The primary outcome of interest was bleeding events [gastrointestinal (GI) bleeding, other anatomical site bleeding (excluding GI), and any bleeding] recorded in the electronic health record that codes using International Classification of Diseases 9th and 10th codes. Known risk factors were used to predict bleeding using multivariate logistic regression. A total of 5492 patients received a DOAC during the study period. Less than half the study population were female (2287, 41.6%). During the follow-up, there were 988 patients (18.0%) experiencing a bleeding event. Of them, 351 patients (35.5%) had a GI bleeding event. Significant risk factors of GI bleeding included clopidogrel [odds ratio (OR) 1.71; 95% confidence interval (95% CI), 1.16-2.52] and previous GI bleeding episodes (OR 7.73; 95% CI, 5.36-11.16). Exposure to corticosteroids (OR 1.50; 95% CI, 1.20-1.87) and previous GI bleeding (OR 1.61; 95% CI, 1.10-2.35) were associated with an increase in bleeding at other anatomical sites (not GI included).

Associated factors of potential drug-drug interactions and drug-food interactions in patients with multiple sclerosis

Background:

Multiple sclerosis (MS) is the most common immune-mediated demyelinating disease in younger adults. Patients with MS (PwMS) are vulnerable to the presence of potential drug–drug interactions (pDDIs) and potential drug–food interactions (pDFIs) as they take numerous medications to treat MS, associated symptoms and comorbidities. Knowledge about pDDIs and pDFIs can increase treatment success and reduce side effects.

Objective:

We aimed at determining the frequency and severity of pDDIs and pDFIs in PwMS, with regard to polypharmacy.

Methods:

In the cross-sectional study, we analysed pDDIs and pDFIs of 627 PwMS aged ⩾18 years. Data collection was performed through patient record reviews, clinical examinations and structured patient interviews. pDDIs and pDFIs were identified using two DDI databases: Drugs.com Interactions Checker and Stockley’s Interactions Checker.

Results:

We identified 2587 pDDIs (counted with repetitions). Of 627 PwMS, 408 (65.1%) had ⩾ 1 pDDI. Polypharmacy (concomitant use of ⩾ 5 drugs) was found for 334 patients (53.3%). Patients with polypharmacy (Pw/P) were found to have a 15-fold higher likelihood of having ⩾ 1 severe pDDI compared with patients without polypharmacy (Pw/oP) (OR: 14.920, p < 0.001). The most frequently recorded severe pDDI was between citalopram and fingolimod. Regarding pDFIs, ibuprofen and alcohol was the most frequent severe pDFI.

Conclusion:

Pw/P were particularly at risk of severe pDDIs. Age and educational level were found to be factors associated with the occurrence of pDDIs, independent of the number of medications taken. Screening for pDDIs/pDFIs should be routinely done by the clinical physician to increase drug safety and reduce side effects.

Prevalence and Severity of Potential Drug–Drug Interactions in Patients with Multiple Sclerosis with and without Polypharmacy

Polypharmacy (PP) is a common problem in modern medicine, especially known to affect patients with chronic diseases such as multiple sclerosis (MS). With an increasing number of drugs taken, the risk of potential drug–drug interactions (pDDIs) is rising. This study aims to assess the prevalence and clinical relevance of polypharmacy and pDDIs in patients with MS. Pharmacological data of 627 patients with MS were entered into two drug–drug-interaction databases to determine the number and severity of pDDIs for each patient. The patients were divided into those with and without PP (total PP and prescription medication PP (Rx PP)). Of the 627 patients included, 53.3% and 38.6% had total PP and Rx PP, respectively. On average, every patient took 5.3 drugs. Of all patients, 63.8% had at least one pDDI with a mean of 4.6 pDDIs per patient. Less than 4% of all pDDIs were moderately severe or severe. Medication schedules should be checked for inappropriate medication and for possible interacting drugs to prevent pDDIs. Physicians as well as pharmacists should be more sensitive towards the relevance of pDDIs and know how they can be detected and avoided.

Potential effect of anti-inflammatory drug use on PSA kinetics and subsequent prostate cancer diagnosis: Risk stratification in black and white men with benign prostate biopsy

BACKGROUND

Rising prostate-specific antigen (PSA) levels are associated with both increased risk of prostate cancer and prostatic inflammation. The confounding effects of inflammation on the utility of PSA kinetics to predict prostate cancer may be partially mitigated by anti-inflammatory drug use. We investigated the influence of anti-inflammatory drug use on the association of PSA kinetics with prostate cancer risk.

METHODS

We studied 488 prostate cancer case-control pairs (290 white, 198 African American (AA)) nested in a retrospective cohort of men with a benign prostate biopsy. A series of multivariable models estimated prostate cancer risk associated with PSA velocity (PSAV) at different levels of anti-inflammatory drug use while adjusting for the presence of both clinical and histologic prostatitis.

RESULTS

In men with one, two, or three or more courses of anti-inflammatory drug use, for each ng/mL/year increase in PSAV, prostate cancer risk increased 1.21-fold, 1.83-fold, and 1.97-fold, respectively ( P < 0.0001). In controls with histologic prostatitis, anti-inflammatory drug use was associated with a significantly lower PSAV ( P < 0.0001). This association was not observed in men with histologic prostatitis who were subsequently diagnosed with prostate cancer. A positive interaction between anti-inflammatory drug use and PSAV-associated prostate cancer risk was only observed in AA men, as well as a strong positive association between any anti-inflammatory drug use and clinical prostatitis ( P = 0.004).

CONCLUSIONS

In men with benign prostate biopsy, accounting for the presence of histologic prostatitis and anti-inflammatory drug use, particularly in AA men, may help distinguish between men with rising PSA because of prostatitis vs undiagnosed cancer.

Prescription and over-the-counter medication record integration: A holistic patient-centered approach

OBJECTIVE

Nonprescription or over-the-counter (OTC) medications play a crucial role in a patient's ability to make choices to manage his or her own health care. Often these nonprescription choices are unknown to health care practitioners and thus are often not included as part of patients' health records. The exclusion of these therapies can pose risks to patient safety. There is a significant need to address the capture of OTC medication use in both the physician and pharmacy electronic health records (EHRs) and during the practitioner-patient medication history and reconciliation process.

DATA SOURCES

On October 26, 2016, the National Association of Chain Drug Stores Foundation hosted a forum for a select group of health care industry professionals to work on a series of recommendations to improve the documentation of OTC medication use by patients. This diverse group of more than a dozen stakeholders included community pharmacy leaders from multiple chain pharmacies, pharmacy system vendors, e-prescribing vendors, health information technology experts, and multiple industry representatives, including individuals from the public sector. This commentary is a summary of the insights and suggestions where the group was in general agreement.

SUMMARY

Successful OTC medication EHR integration will require system-level buy-in across multiple layers of the health care industry to improve patient safety. Forum participants suggested incremental steps that could be taken by multiple stakeholders to lay the foundation for integration within an appropriate regulatory structure.

CONCLUSION

Based on the results of the stakeholder forum, an agreement formed around one approach that the group supported as feasible: the creation of a consistent and uniform identification method for OTC medications in cooperation with government regulatory authorities.

Prevalence of drug-drug interactions at hospital entry and during hospital stay of patients in internal medicine

OBJECTIVE

The aim of this study was to assess potential drug-drug interactions (pDDIs) at hospital admission, during hospitalization and at discharge and to evaluate the number of pDDIs created during hospitalization.

METHODS

The medication of 851 patients was screened for pDDIs (major and moderate severity) using the screening program Pharmavista. The frequency of pDDIs per patient, per number of drugs and drug pairs was estimated.

RESULTS

During hospitalization, the frequency of major and moderate pDDIs per patient was 1.11, which was higher compared to hospital admission (0.59) or to hospital discharge (0.60). The frequency of major and moderate pDDIs per drug prescribed (13.7% vs. 9.1%) or per drug pairs analyzed (4.5% vs. 2.3%) was higher at hospital admission compared to hospital discharge. 47% of all major and moderate pDDIs at discharge were due to a medication change during hospitalization.

CONCLUSIONS

Although the number of major and moderate pDDIs per patient did not increase from hospital admission to discharge, it is important to realize that 47% of all major and moderate DDIs at hospital discharge were created during hospitalization. Prescribing drugs with a low risk for pDDIs as well as careful monitoring for adverse drug reactions are important measures to minimize harm associated with DDIs.