Agreement between PRE2DUP register data modeling method and comprehensive drug use interview among older persons

Real-world use of pharmacological treatments for incident bipolar disorder: A Finnish nationwide cohort study

BACKGROUND

Pharmacotherapy remains crucial for treating bipolar disorder (BD), but knowledge on the treatments actually used by newly diagnosed patients in real-world settings is sparse.

METHODS

Individuals newly diagnosed with BD during 1996-2018, aged 15-65 years, were identified from national Finnish registers. The patients' use of different drug classes (mood stabilizers, antipsychotics and antidepressants) or combinations of these drug classes were followed from initial pharmacotherapy (first line) after BD diagnosis until the fifth line of treatment or until the two-year follow-up time ended. Clinical and sociodemographic factors associated with antidepressants-only as the first treatment line were assessed with logistic regression.

RESULTS

82.6 % of all patients used BD medication during the follow-up. 33.9 % had antidepressants-only as the first, 22.9 % as the second and 19.7 % as the third treatment line. Use of combinations of mood stabilizers, antipsychotics and antidepressants increased by successive treatment lines. Factors associated with antidepressants-only as the first treatment line included older age (>45 years aOR 2.20, 95% CI: 2.01-2.40, 25-45 years: 1.55, 1.42-1.68, compared with those aged <25), diabetes (1.35, 1.17-1.55) and female sex (1.29, 1.21-1.37). BD diagnosis registered in 2016-2018 (0.48, 0.42-0.55) and substance abuse (0.77, 0.71-0.83) were associated with decreased odds.

LIMITATIONS

Due to the register-based nature of this study, not all potentially important clinical factors influencing medication use could be controlled for.

CONCLUSIONS

A large proportion of patients with bipolar disorder are not treated according to treatment guidelines, as use of antidepressants alone is common. Reasons for not following evidence-based recommendations need to be further researched.

Real-world effectiveness of pharmacological treatments for bipolar disorder: register-based national cohort study

BACKGROUND

Pharmacological treatment patterns for bipolar disorder have changed during recent years, but for better or worse?

AIMS

To investigate the comparative real-world effectiveness of antipsychotics and mood stabilisers in bipolar disorder.

METHOD

Register-based cohort study including all Finnish residents aged 16-65 with a diagnosis of bipolar disorder from in-patient care, specialised out-patient care, sickness absence and disability pensions registers between 1996 and 2018, with a mean follow-up of 9.3 years (s.d. = 6.4). Antipsychotic and mood stabiliser use was modelled using the PRE2DUP method and risk for hospital admission for psychiatric and non-psychiatric reasons when using versus not using medications was estimated using within-individual Cox models.

RESULTS

Among 60 045 individuals (56.4% female; mean age 41.7 years, s.d. = 15.8), the five medications associated with lowest risk of psychiatric admissions were olanzapine long-acting injection (LAI) (aHR = 0.54, 95% CI 0.37-0.80), haloperidol LAI (aHR = 0.62, 0.47-0.81), zuclopenthixol LAI (aHR = 0.66, 95% CI 0.52-0.85), lithium (aHR = 0.74, 95% CI 0.71-0.76) and clozapine (aHR = 0.75, 95% CI 0.64-0.87). Only ziprasidone (aHR = 1.26, 95% CI 1.07-1.49) was associated with a statistically higher risk. For non-psychiatric (somatic) admissions, only lithium (aHR = 0.77, 95% CI 0.74-0.81) and carbamazepine (aHR = 0.91, 95% CI 0.85-0.97) were associated with significantly reduced risk, whereas pregabalin, gabapentin and several oral antipsychotics, including quetiapine, were associated with an increased risk. Results for a subcohort of first-episode patients (26 395 individuals, 54.9% female; mean age 38.2 years, s.d. = 13.0) were in line with those of the total cohort.

CONCLUSIONS

Lithium and certain LAI antipsychotics were associated with lowest risks of psychiatric admission. Lithium was the only treatment associated with decreased risk of both psychiatric and somatic admissions.

Real-world effectiveness of antidepressant use in persons with schizophrenia: within-individual study of 61,889 subjects

The aim of this study was to investigate the real-world effectiveness of antidepressant use in persons with schizophrenia. The register-based study cohort included all 61,889 persons treated in inpatient care due to schizophrenia during 1972-2014 in Finland. The main outcome was hospitalization due to psychosis and secondary outcomes included non-psychiatric hospitalization and all-cause mortality. We used within-individual design to compare the risk of hospitalization-based outcomes during the time periods of antidepressant use to antidepressant non-use periods within the same person, and traditional between-individual Cox models for mortality. The risk of psychosis hospitalization was lower during antidepressant use as compared to non-use (adjusted Hazard Ratio, aHR, 0.93, 95% CI 0.92-0.95). Antidepressants were associated with a decreased risk of mortality (aHR 0.80, 95% CI 0.76-0.85) and a slightly increased risk of non-psychiatric hospitalization (aHR 1.03, 95% CI 1.01-1.06). In conclusion, these results indicate that antidepressants might be useful and relatively safe to use in this population.

Real-world effectiveness of mood stabilizer use in schizophrenia

OBJECTIVE

Mood stabilizers (MS) are often used as adjunctive medication in patients with schizophrenia. The aim of this study was to investigate the real-world effectiveness of MS use in persons with schizophrenia.

METHODS

The study cohort included all persons treated in inpatient care due to schizophrenia during 1972-2014 in Finland (N = 61,889). Drug purchase data were obtained from the national Prescription register and modeled with the PRE2DUP method. The follow-up period covered the years 1996-2017. Mood stabilizers included carbamazepine, valproic acid, lamotrigine, and lithium. The main outcome was psychosis hospitalization. We utilized within-individual design to compare the risk of outcome between time-periods of MS use and non-use within the same person. Stratified Cox regression analyses were conducted with adjusted hazard ratios (aHR) and 95% confidence intervals (CIs).

RESULTS

Mean age at cohort entry was 46.2 years (SD 16.0) and 50.3% were male. During the follow-up (maximum of 22 years, median 14.8 years, interquartile range 7.5-22.0), 28.1% (N = 17,370) of the study cohort used MS, valproic acid being the most often used one (60.4%, N = 10,483). Risk of psychosis hospitalization was lower during MS use than non-use (aHR 0.88, 95% CI 0.86-0.90). Use of lithium (0.84, 0.81-0.87), valproic acid (0.87, 0.85-0.90), and lamotrigine (0.90, 0.85-0.95) were associated with lower risk of psychosis hospitalization compared with their non-use, whereas carbamazepine use was not.

CONCLUSIONS

Mood stabilizers were relatively often used as adjunctive treatments in schizophrenia and their use was associated with a 12% decreased risk of psychosis rehospitalization, a marker of relapse in schizophrenia.

A data-informed approach using individualised dispensing patterns to estimate medicine exposure periods and dose from pharmaceutical claims data

Pharmaceutical claims data are often used as the primary information source to define medicine exposure periods in pharmacoepidemiological studies. However, often critical information on directions for use and the intended duration of medicine supply are not available. In the absence of this information, alternative approaches are needed to support the assignment of exposure periods. This study summarises the key methods commonly used to estimate medicine exposure periods and dose from pharmaceutical claims data; and describes a method using individualised dispensing patterns to define time-dependent estimates of medicine exposure and dose. This method extends on important features of existing methods and also accounts for recent changes in an individual's medicine use. Specifically, this method constructs medicine exposure periods and estimates the dose used by considering characteristics from an individual's prior dispensings, accounting for the time between prior dispensings and the amount supplied at prior dispensings. Guidance on the practical applications of this method is also provided. Although developed primarily for application to databases, which do not contain duration of supply or dose information, use of this method may also facilitate investigations when such information is available and there is a need to consider individualised and/or changing dosing regimens. By shifting the reliance on prescribed duration and dose to determine exposure and dose estimates, individualised dispensing information is used to estimate patterns of exposure and dose for an individual. Reflecting real-world individualised use of medicines with complex and variable dosing regimens, this method offers a pragmatic approach that can be applied to all medicine classes.

Continuity of antipsychotic medication use among migrant and Finnish-born populations with a psychotic disorder: a register-based study

BACKGROUND

Higher incidence of psychotic disorders and underuse of mental health services have been reported among many migrant populations. This study examines the initiation and continuity of antipsychotic treatment among migrants and non-migrants with a non-affective psychosis during a new treatment episode.

METHODS

This study is based on a nationwide sample of migrants and Finnish-born controls. Participants who were diagnosed with a psychotic disorder in 2011-2014 were identified from the Care Register for Health Care (n = 1693). Information on purchases of antipsychotic drugs in 2011-2015 was collected from the National Prescription Register. The duration of antipsychotic treatment since diagnosis was estimated using the PRE2DUP model. Cox regression analysis was used to study factors that are associated with discontinuing the use of medication.

RESULTS

There were fewer initiators of antipsychotic treatment after being diagnosed with psychosis among migrants (68.1%) than among Finnish-born patients (73.6%). After controlling for sociodemographic background and factors related to the type of disorder and treatment, migrants were more likely to discontinue medication (adjusted hazard ratio 1.28, 95% confidence interval 1.08-1.52). The risk of discontinuation was highest among migrants from North Africa and the Middle East and Sub-Saharan Africa and among recent migrants. Non-use of antipsychotic treatment before being diagnosed with psychosis, involuntary hospitalization and diagnosis other than schizophrenia were associated with earlier discontinuation both among migrants and non-migrants.

CONCLUSIONS

Migrants with a psychotic disorder are less likely to continue antipsychotic treatment than non-migrants. The needs of migrant patients have to be addressed to improve adherence.

Allopurinol, dipyridamole and calcium channel blockers in the treatment of bipolar disorder - A nationwide cohort study

BACKGROUND

Improved treatments for bipolar disorder (BD) are needed. Drug repurposing aims to find novel targets for drugs that have been used for other indications. This study investigated the risk of psychiatric hospitalization associated with use of calcium-channel blockers (CCBs; dihydropyridines, diltiazem, verapamil) and adenosine modulators (allopurinol, dipyridamole) in BD in within-individual design.

METHODS

Individuals diagnosed with BD (ICD-10: F30-F31) were identified from the inpatient, specialized outpatient, sickness absence, and disability pension registers during 1996-2018 in Finland (N = 60,045). The main outcome was hospitalization due to affective symptoms (ICD-10: F30-F39). Within-individual models in stratified Cox regression were used and adjusted hazard ratios (aHR) with 95 % confidence intervals (CIs) reported.

RESULTS

Use of CCBs was associated with a decreased risk of hospitalization due to affective symptoms (aHR 0.83, 95 % CI 0.78-0.88) when all CCBs were analyzed together. Of specific CCBs, use of diltiazem (0.71, 0.55-0.91) and dihydropyridines (0.83, 0.78-0.89) were associated with a decreased risk but verapamil was not (0.93, 0.73-1.19). Use of adenosine modulators in general was associated with a decreased risk of hospitalizations due to affective symptoms (0.87, 0.79-0.96). Both allopurinol (0.85, 0.74-0.97) and dipyridamole (0.89, 0.78-1.00) were associated with a marginally decreased risk. Thiazide diuretic use as a negative control was not associated with the risk of hospitalization due to affective symptoms (0.97, 0.83-1.13).

LIMITATIONS

Due to the observational nature of this study, causation cannot be confirmed.

CONCLUSIONS

Dihydropyridines and diltiazem were associated with a decreased risk of psychiatric hospitalization in bipolar disorder. Results for allopurinol and dipyridamole were inconclusive.

Comparative effectiveness of mood stabilizers and antipsychotics in the prevention of hospitalization after lithium discontinuation in bipolar disorder

The aim of the study was to compare the real-world effectiveness of mood stabilizers and antipsychotics in the prevention of psychiatric hospitalizations and treatment failure after lithium discontinuation in a nationwide bipolar cohort. Using health-care registers, we identified everyone in Finland diagnosed with bipolar disorder during 1987-2018 who discontinued lithium after using it for at least one year (n = 4 052, median period of lithium use before discontinuation 2.7 years). The risk of psychiatric hospitalization and treatment failure (psychiatric hospitalization, death or change in medication) were investigated with within-individual Cox regression. Of mood stabilizer monotherapies, the periods of valproate use (HR = 0.83, 95% CI = 0.71 - 0.97) had lower risk of hospitalization than nonuse of mood stabilizers. Of antipsychotic monotherapies, the use of long-acting injectable (LAI) antipsychotics (HR = 0.48, 95% CI = 0.26 - 0.88) and chlorprothixene (HR = 0.62, 95% CI = 0.44 - 0.88) were associated with lower risk and the use of quetiapine (HR = 1.26, 95% CI = 1.07 - 1.48) and oral olanzapine (HR = 1.23, 95% CI = 1.01 - 1.49) with higher risk of psychiatric hospitalizations than nonuse of antipsychotics. Of mood stabilizer monotherapies, lithium use was associated with lower risk of treatment failure (HR = 0.82, 95% CI = 0.76 - 0.88) than valproate use. The results suggest that antipsychotic LAIs are especially effective in the prevention of psychiatric hospitalizations after lithium discontinuation. The need to alter used medications may be the lowest when lithium is restarted.

Real-world effectiveness of pharmacological treatments of opioid use disorder in a national cohort

AIM

To investigate the real-world effectiveness of pharmacological treatments (buprenorphine, methadone) of opioid use disorder (OUD).

DESIGN

A nation-wide, register-based cohort study.

SETTING

Sweden.

PARTICIPANTS

All residents aged 16-64 years living in Sweden using OUD medication from July 2005 to December 2016 (n = 5757, 71.8% men) were identified from registers of prescriptions, inpatient and specialized outpatient care, causes of death, sickness absence and disability pensions.

MEASUREMENTS

Main outcome: hospitalization due to OUD.

SECONDARY OUTCOMES

hospitalization due to any cause; death due to all, natural and external causes. Mortality was analyzed with between-individual multivariate-adjusted Cox hazards regression model. Recurrent outcomes, such as hospitalizations, were analyzed with within-individual analyses to eliminate selection bias. OUD medication use versus non-use was modelled with PRE2DUP (from prescription drug purchases to drug use periods) method.

FINDINGS

Buprenorphine [hazard ratio (HR) = 0.73, 95% confidence interval (CI) = 0.54-0.97] and methadone (HR = 0.74, 95% CI = 0.59-0.93) use were associated with significantly lower risk of OUD hospitalization, but not any-cause hospitalizations, compared with the time-periods when the same individual did not use OUD medication. The use of buprenorphine and methadone were both associated with significantly lower risk of all-cause mortality (HR = 0.45, 95% CI = 0.34-0.59; HR = 0.51, 95% CI = 0.41-0.63, respectively), compared with non-use of both medications. Similar results were found for risk of mortality due to external causes (HR = 0.39; 95% CI = 0.27-0.54; HR = 0.40; 95% CI = 0.29-0.53, respectively), but not for mortality due to natural causes. The risk of OUD hospitalization and all-cause mortality was decreased in all duration categories of studied medications (< 30, 31-180, 181-365 and >365 days), except for methadone use less than 30 days.

CONCLUSIONS

The use of buprenorphine and methadone are both associated with a significantly lower risk of hospitalization due to opioid use disorder and death due to all and external causes, when compared with non-use.

Prevalence of oral anticoagulant use among people with and without Alzheimer’s disease

Background

Although cardio- and cerebrovascular diseases are common among people with Alzheimer’s disease (AD), it is unknown how the prevalence of oral anticoagulant (OAC) use changes in relation to AD diagnosis. We investigated the prevalence of OAC use in relation to AD diagnosis in comparison to a matched cohort without AD.

Methods

Register-based Medication use and Alzheimer’s disease (MEDALZ) cohort includes 70 718 Finnish people with AD diagnosed between 2005–2011. Point prevalence of OAC use (prescription register) was calculated every three months with three-month evaluation periods, from five years before to five years after clinically verified diagnosis and compared to matched cohort without AD. Longitudinal association between AD and OAC use was evaluated by generalized estimating equations (GEE).

Results

OAC use was more common among people with AD until AD diagnosis, (OR 1.17; 95% CI 1.13–1.22), and less common after AD diagnosis (OR 0.87; 95% CI 0.85–0.89), compared to people without AD. At the time of AD diagnosis, prevalence was 23% and 20% among people with and without AD, respectively. OAC use among people with AD began to decline gradually two years after AD diagnosis while continuous increase was observed in the comparison cohort. Warfarin was the most common OAC, and atrial fibrillation was the most common comorbidity in OAC users.

Conclusion

Decline in OAC use among people with AD after diagnosis may be attributed to high risk of falling and problems in monitoring. However, direct oral anticoagulants (DOACs) that are nowadays more commonly used require less monitoring and may also be safer for vulnerable people with AD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03144-x.

Changes in the use of diabetes drugs among community-dwelling people with Alzheimer's disease

Background

Type 2 diabetes is common in persons with Alzheimer’s disease (AD). Management of diabetes in persons with AD is challenging due to changing goals of care and susceptibility to adverse drug events including hypoglycemia. The aim of this study was to investigate the prevalence of diabetes drug use from 5 years before to 5 years after the time of AD diagnosis among persons with and without AD.

Methods

This was a nationwide register-based study of persons with and without AD and diabetes in Finland. We analyzed data from the Medication Use and Alzheimer’s disease (MEDALZ) study that included 70,718 community-dwelling people diagnosed with AD from 2005 to 2011. The study population included 8418 persons with AD and 6666 matched persons without AD who were diagnosed with diabetes 5 years before AD diagnosis (index date). We defined the prevalence of diabetes drug use in three-month evaluation periods from 5 years before until 5 years after the index date.

Results

Nearly all people with diabetes (94% in both cohorts) used one or more diabetes drugs on the index date. The most prevalent drug metformin was used by 60.9% of people with AD and 59.1% of people without AD. The next most prevalent drugs were sulfonylureas and insulin. The prevalence of diabetes drug use was similar in people with and without AD but began to decline 1 year after AD diagnosis in the AD cohort compared to non-AD cohort.

Conclusions

The decline in diabetes drug use after AD diagnosis may be attributed to clinicians and patients seeking to avoid serious adverse drug events including hypoglycemia. In addition, the findings may reflect personalized glycemic control and unintentional weight loss in persons with AD reducing the need for diabetes drugs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02694-w.

Persistence of antidepressant use among refugee youth with common mental disorder

BACKGROUND

The objective of this study was to investigate whether persistence of antidepressant use differs between refugee youth and Swedish-born youth after a diagnosis of a common mental disorder (CMD), and if clinical and sociodemographic factors are associated with antidepressant discontinuation.

METHODS

Youth aged 16-25 years, with an incident diagnosis of CMD (depression, post-traumatic stress disorder (PTSD), anxiety disorders) accessing specialized healthcare in Sweden 2006-2016 were included. New users were identified with a one-year washout period. Refugees (N=1575) were compared with Swedish-born youth (N=2319). Cox regression models [reported as adjusted Hazard Ratios (HRs) with 95% confidence intervals (CIs)] were used to investigate factors associated with discontinuation of antidepressant use.

RESULTS

Among youth (mean age 20.9 years, SD 2.7, 50% females), the median duration of antidepressant use differed considerably between refugee (101 days, IQR 31-243) and Swedish-born youth (252 days, IQR 101-558). Refugees were more likely to discontinue treatment (HR 1.61, 95% CI 1.47-1.77). Factors associated with an increased risk for discontinuation in refugees included ≤5 years duration of formal residency (HR 1.28, 95% CI 1.12-1.45), antidepressant type, and dispensing lag (time from prescription to dispensing) of >7 days (1.43, 1.25-1.64), whereas PTSD (0.78, 0.64-0.97) and anxiolytic use (0.79, 0.64-0.96) were associated with a lower discontinuation risk.

LIMITATIONS

Only persons treated in specialized healthcare could be included.

CONCLUSION

The relatively short treatment durations among refugee youth suggest that antidepressant treatment may not be optimal in CMD, and better monitoring of treatment as well as transcultural education of healthcare personnel are warranted.

Real-world effectiveness of pharmacological treatments of alcohol use disorders in a Swedish nation-wide cohort of 125 556 patients

BACKGROUND AND AIM

Pharmacotherapy for alcohol use disorder (AUD) is recommendable, but under-used, possibly due to deficient knowledge of medications. This study aimed to investigate the real-world effectiveness of approved pharmacological treatments (disulfiram, acamprosate, naltrexone and nalmefene) of AUD.

DESIGN

A nation-wide, register-based cohort study.

SETTING

Sweden.

PARTICIPANTS

All residents aged 16-64 years living in Sweden with registered first-time treatment contact due to AUD from July 2006 to December 2016 (n = 125 556, 62.5% men) were identified from nation-wide registers.

MEASUREMENTS

The main outcome was hospitalization due to AUD. The secondary outcomes were hospitalization due to any cause, alcohol-related somatic causes, as well as work disability (sickness absence or disability pension), and death. Mortality was analysed with between-individual analysis using a traditional multivariate-adjusted Cox hazards regression model. Recurrent outcomes, such as hospitalization-based events and work disability, were analysed with within-individual analyses to eliminate selection bias.

FINDINGS

Naltrexone combined with acamprosate [hazard ratio (HR) = 0.74; 95% confidence interval (CI) = 0.61-0.89], combined with disulfiram (HR = 0.76, 95% CI = 0.60-0.96) and as monotherapy (HR = 0.89, 95% CI = 0.81-0.97) was associated with a significantly lower risk of AUD-hospitalization compared with no use of AUD medication. Similar results were found for risk of hospitalization due to any cause. Benzodiazepine use and acamprosate monotherapy were associated with an increased risk of AUD-hospitalization (HR = 1.18, 95% CI = 1.14-1.22 and HR = 1.10, 95% CI = 1.04-1.17, respectively). No statistically significant effects were found for work disability or mortality.

CONCLUSIONS

Naltrexone as monotherapy and when combined with disulfiram and acamprosate appears to be associated with lower risk of hospitalization due to any and alcohol-related causes, compared with no use of alcohol use disorder (AUD) medication. Acamprosate monotherapy and benzodiazepine use appear to be associated with increased risk of AUD-associated hospitalization.

Hip Fracture Risk in Antiepileptic Drug Initiators and Non-Initiators with Alzheimer's Disease

Objective

To determine the risk of hip fracture in persons with Alzheimer´s disease (AD) who initiated antiepileptic drugs (AEDs).

Methods

In the Medication use and AD (MEDALZ) cohort of 70,719 Finnish community dwellers with clinically verified incident AD diagnosis in 2005-2011, we identified all incident users of AEDs using national Prescription register. AEDs were classified as older (valproate, carbamazepine, clonazepam, phenytoin, levetiracetam, primidone) or newer (pregabalin, gabapentin, oxcarbazepine, lamotrigine, topiramate). We matched each user to 2 non-users. Incident hip fractures until 2015 were identified from the Care register for health care. We calculated inverse probability of treatment weighted hazard ratios (HR), with 95% confidence intervals, using Cox regression.

Results

Altogether 5522 incident users were identified and matched to 11,044 non-users (in both groups, women: 65%; median age: 81 years). Altogether 53.3% of users initiated with newer AEDs (pregabalin 79.8%, gabapentin 10.2%) while 46.7% initiated with older AEDs (valproate 67.6%, carbamazepine 13.0%). Age- and sex-adjusted IR of hip fracture per 100 person-years was 1.8 (95% CI 1.6-1.9) in non-users and 2.0 (95% CI 1.8-2.2) in users. Increased risk of hip fracture was observed in users (HR 1.17, 95% CI 1.05-1.30) compared with non-users. The risk was higher for short duration of use (<14 weeks, HR 3.64, 95% CI 2.90-4.58) than for medium duration (14 to <64 weeks, HR 1.74, 95% CI 1.48-2.05) or ≥64 weeks' use (HR 1.23, 95% CI 1.08-1.40), compared to non-users with same follow-up time. Older AEDs had HR of 1.46 (1.03-2.08) compared with newer AEDs.

Conclusion

Our results imply that AED use is associated with an increased risk of hip fracture in people with AD. These findings prompt careful consideration before prescribing AEDs to persons with AD. Persons with AD treated with antiepileptics should be carefully monitored due to their increased risk of falling and fractures.

Length of Hospital Stay for Hip Fracture and 30-Day Mortality in People With Alzheimer's Disease: A Cohort Study in Finland

Background

Persons with Alzheimer’s disease (AD) are at higher risk of hip fractures (HFs) than general older population and have worse prognosis after HF. Hospital stays after HF have shortened along time. We investigated the association between length of hospital stay after HF and mortality after discharge among persons with AD.

Method

The MEDALZ cohort includes all Finnish community dwellers who received clinically verified AD diagnosis in 2005–2011 (N = 70 718). Patients who experienced first HF after AD diagnosis in 2005‒2015 (n = 6999) were selected. Length of hospital stay for HF was measured as a sum of the consecutive days spent in hospital after HF until discharge. Outcome was defined as death within 30 days after hospital discharge.

Results

Mean of overall length of hospital stay after a HF decreased from 52.6 (SD 62.9) days in 2005 to 19.6 (SD 23.1) days in 2015. Shortest treatment decile (1‒4 days) had the highest risk of death within 30 days after discharge (adjusted hazard ratio [aHR] 2.76; 95% confidence interval [CI] 1.66–4.60) in addition to second (5‒6 days; aHR 2.52; 95% CI 1.50–4.23) and third (7‒10 days; aHR 2.22; 95% CI 1.34–3.69) deciles when compared to the sixth decile of length of stays (21‒26 days).

Conclusions

Among persons with AD, shorter length of hospital stay after HF was associated with an increased risk of death after discharge. After acute HF treatment, inpatient rehabilitation or proper care and services in home need to be organized to older persons with AD.

Long-Term Real-World Effectiveness of Pharmacotherapies for Schizoaffective Disorder

OBJECTIVE

To investigate the long-term real-world effectiveness of antipsychotics and other psychopharmacotherapies in the treatment of schizoaffective disorder (SCHAFF).

METHOD

Two nationwide cohorts of SCHAFF patients were identified from Finnish and Swedish registers. Within-individual design was used with stratified Cox regression. The main exposure was use of antipsychotics. Adjunctive pharmacotherapies included mood stabilizers, antidepressants, and benzodiazepines and benzodiazepine-related drugs. The main outcome was hospitalization due to psychosis.

RESULTS

The Finnish cohort included 7655 and the Swedish cohort 7525 patients. Median follow-up time was 11.2 years (IQR 5.6-11.5) in the Finnish and 7.6 years (IQR 3.8-10.3) in the Swedish cohort. Clozapine and long-acting injectable (LAI) antipsychotics were consistently associated with a decreased risk of psychosis hospitalization and treatment failure (psychiatric hospitalization, any change in medication, death) in both cohorts. Quetiapine was not associated with a decreased risk of psychosis hospitalization. Mood stabilizers used in combination with antipsychotics were associated with a decreased risk of psychosis hospitalization (Finnish cohort HR 0.76, 95% CI 0.71-0.81; Swedish cohort HR 0.84, 0.78-0.90) when compared with antipsychotic monotherapy. Combination of antidepressants and antipsychotics was associated with a decreased risk of psychosis hospitalization in the Swedish cohort (HR 0.90, 0.83-0.97) but not in the Finnish cohort (1.00, 0.94-1.07), and benzodiazepine use was associated with an increased risk (Finnish cohort HR 1.07, 1.01-1.14; Swedish cohort 1.21, 1.13-1.30).

CONCLUSIONS

Clozapine, LAIs, and combination therapy with mood stabilizers were associated with the best outcome and use of quetiapine and benzodiazepines with the worst outcome in the treatment of SCHAFF.

Effectiveness of pharmacotherapies for delusional disorder in a Swedish national cohort of 9076 patients

BACKGROUND

Little is known on the effective pharmacological treatment of delusional disorder.

AIMS

Study the comparative effectiveness of pharmacotherapies in the prevention of hospitalization due to psychosis and work disability in delusional disorder.

METHODS

Observational registry based cohort study including everyone in Sweden diagnosed with delusional disorder (N = 9076;mean follow-up time 4.9 years). The primary analysis was Cox Proportional Hazards within-individual analysis. Results are reported as adjusted hazard ratios (HRs).

RESULTS

Among the cohort (4835 males/4241 females;mean [SD] age 44.1 [12.5] years), 2074 persons had at least one hospitalization due to psychosis. Risk for hospitalization due to psychosis was 46% lower when any antipsychotic was used (HR 0.54, 95%CI 0.38-0.77, p < 0.001). Use of clozapine (HR 0.24, 95%CI 0.07-0.77, p = 0.016), any long-acting injectable (LAI; HR 0.28, 95%CI 0.16-0.49, p < 0.0001) and oral olanzapine (HR 0.36, 95%CI 0.20-0.67, p = 0.001) were associated with lowest risk. Among those not on disability pension at start of follow-up (n = 5025), in comparison to no use of antipsychotics, use of clozapine (HR 0.08, 95%CI 0.01-0.52, p = 0.008), any LAI (HR 0.44, 95%CI 0.25-0.79, p = 0.006) and oral aripiprazole (HR 0.52, 95%CI 0.31-0.85, p = 0.009) were associated with lowest risk of work disability.

CONCLUSIONS

Use of antipsychotics was associated with a reduced risk of hospitalization due to psychosis and work disability in delusional disorder, with use of clozapine and long-acting injectables being associated with the lowest risk for these very relevant end-points for both individual suffering and costs to society. Clinical trials with these treatments are urgently needed to make informed clinical treatment recommendations.

Adenosine modulators and calcium channel blockers as add-on treatment for schizophrenia

Relapses remain common among individuals with schizophrenia indicating a need for improved treatments. Creating a completely new drug molecule is expensive and time consuming, and therefore drug repurposing should be considered. Aim of this study was to investigate the risk of psychiatric rehospitalization associated with use of adenosine modulators (AMs) and calcium channel blockers (CCBs) in schizophrenia. Individuals diagnosed with schizophrenia (N = 61,889) in inpatient care between 1972–2014 in Finland were included. The follow-up lasted from 1996 to 2017. Main exposures were use of AMs (allopurinol and dipyridamole) and CCBs (dihydropyridines, diltiazem, and verapamil). Thiazide diuretics were used as a negative control. Within-individual models in stratified Cox regression were used and adjusted hazard ratios (HR) with 95% confidence intervals (CIs) are reported. Use of AMs was associated with a reduced risk of psychiatric rehospitalization on drug class level (HR 0.74, 95% CI 0.65–0.84, P < 0.0001), as well as on the level of individual drugs (allopurinol HR 0.82, 95% CI 0.70–0.97, P = 0.02; dipyridamole HR 0.65, 95% CI 0.55–0.77, P < 0.0001). Use of CCBs was associated with a reduced risk of psychiatric rehospitalization on drug class level (HR 0.81, 95% CI 0.77–0.86, P < 0.0001). From the different CCBs, only exposure to dihydropyridines was associated with a reduced risk (HR 0.79, 95% CI 0.74–0.84, P < 0.0001). No effect was observed for the negative control, thiazide diuretics (HR 0.96, 0.90–1.02, P = 0.20). The effects of dipyridamole and dihydropyridines were more pronounced among younger persons and combination of AMs, and CCBs was associated with a lower risk than either drug class as monotherapy. These results indicate a need for randomized controlled trials of these drugs.

Suicide mortality and use of psychotropic drugs in patients hospitalized due to bipolar disorder: A Finnish nationwide cohort study

BACKGROUND

Knowledge on the comparative effectiveness of pharmacological treatments to prevent suicide mortality in bipolar disorder is still lacking.

METHODS

We studied the risk of suicide mortality during 1996-2012 among all patients who had been hospitalized due to bipolar disorder in Finland (n = 18,018; mean follow-up time 7.2 years) using nation-wide databases. We used a Cox proportional hazards model. Analyses were adjusted for the effects of time since diagnosis, order of treatments, current use of other treatments, polypharmacy, number of suicidal hospitalizations within 2 year (indicator of inherent risk of relapse), age at index date, sex, and calendar year of index date. In secondary analysis, the first 30 days were omitted from analysis after initiation of a psychopharmacological treatment to control for protopathic bias.

RESULTS

In comparison between use and no use among specific agents, only lithium (HR 0.33, 95%CI 0.24-0.47, p<0.0001) and valproic acid (HR 0.61, 95%CI 0.48-0.79, p=0.0002) were associated with a significantly decreased risk of suicide in bipolar disorder. Lithium showed a 42% lower risk for suicide mortality compared to valproic acid (HR 0.58, 95% CI 0.39-0.86, p = 0.007). Hypnotics were associated with a significantly (HR 1.52, 95%CI 1.22-1.90, p=0.0002) higher risk of suicide.

LIMITATIONS

Only hospitalized patients were included.

CONCLUSIONS

Lithium should be considered as treatment of choice for patients with bipolar disorder who are at high risk for suicide. Hypnotic use among suicidal patients indicates need for close monitoring of these patients.

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

IMPORTANCE

The proportion of patients who develop long-term benzodiazepine use remains controversial, as do the length of time before long-term use develops and the factors associated with long-term use.

OBJECTIVE

To investigate the incidence of long-term benzodiazepine and related drug (BZDR) use and factors associated with the development of long-term use implementing a follow-up design with new BZDR users.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used a nationwide cohort of 129 732 new BZDR users in Finland. New users of BZDRs aged 18 years or older were identified from the prescription register maintained by the Social Insurance Institution of Finland as individuals who initiated BZDR use during 2006 and had not used BZDRs from 2004 to 2005. The follow-up continued until death, long-term hospitalization, a gap of 2 years in BZDR use, or December 31, 2015. The population was analyzed according to age at treatment initiation, categorized into younger (<65 years) and older (≥65 years) subcohorts. Analyses were conducted from May 2019 to February 2020.

EXPOSURES

Use of BZDRs, modeled from register-based data using the PRE2DUP (from prescriptions to drug use periods) method.

MAIN OUTCOMES AND MEASURES

Long-term BZDR use, defined as continuous use of 180 days or longer, and factors associated with long-term vs short-term use, compared using Cox proportional hazards models.

RESULTS

Among the 129 732 incident BZDR users, the mean (SD) age was 52.6 (17.7) years, and 78 017 (60.1%) individuals were women. During the follow-up period, 51 099 BZDR users (39.4%) became long-term users. Long-term treatment was more common in the older subcohort (19 103 individuals [54.5%]) than the younger subcohort (31 996 individuals [33.8%]). At 6 months, 28 586 individuals (22.0%) had become long-term users: 11 805 (33.7%) in the older subcohort and 16 781 (17.7%) in the younger subcohort. The largest proportions of initiators who became long-term users were those persons who initiated treatment with nitrazepam (76.4%; 95% CI, 73.6%-79.1%), temazepam (63.9%; 95% CI, 62.9%-65.0%), lorazepam (62.4%; 95% CI, 59.7%-65.1%), or clonazepam (57.5%; 95% CI, 55.9%-59.2%). Factors associated with the development of long-term use included male sex, older age, receipt of social benefits, psychiatric comorbidities, and substance abuse.

CONCLUSIONS AND RELEVANCE

The findings of this population-based cohort study conducted in Finland suggest that the incidence of subsequent long-term BZDR use in individuals who initiate use of BZDRs is high, especially among older persons, and that the specific BZDR used initially is associated with the development of long-term BZDR use and should be carefully considered when prescribing BZDRs. The observed factors that appear to be associated with development of long-term BZDR use also should be considered in clinical decision-making when starting and monitoring BZDR treatment.

In the aftermath of clozapine discontinuation: comparative effectiveness and safety of antipsychotics in patients with schizophrenia who discontinue clozapine

BACKGROUND

Although clozapine is often discontinued, there is a paucity of guidelines and evidence on treatment options after clozapine discontinuation. Moreover, it is currently unknown whether reinstating clozapine in patients formerly using clozapine should be avoided.

AIMS

To compare the real-world effectiveness of antipsychotics after clozapine cessation.

METHOD

From Finnish registry data (1995-2017), we identified 2250 patients with schizophrenia who had been using clozapine for ≥1 year before treatment cessation. The primary analysis consisted of adjusted within-individual analyses of psychiatric ward readmission owing to psychosis and treatment failure. Secondary analyses concerned between-individual mortality differences.

RESULTS

Compared with no use of antipsychotics, risk of psychiatric ward readmission was lowest for reinitiation of clozapine (adjusted hazard ratio (aHR) 0.49; 95% CI 0.40-0.61; P < 0.0001), oral olanzapine (aHR 0.58; 95% CI 0.48-0.71; P < 0.0001) and antipsychotic polypharmacy (aHR 0.62; 95% CI 0.53-0.72; P < 0.0001). Risk of treatment failure was lowest for aripiprazole long acting injectable (aHR 0.42; 95% CI 0.27-0.65; P < 0.0001), reinitiation of clozapine (aHR 0.49; 95% CI 0.43-0.57; P < 0.0001) and oral olanzapine (aHR 0.69; 95% CI 0.61-0.77; P < 0.0001). Mortality risk was lowest for reinitiation of clozapine (aHR 0.18; 95% CI 0.09-0.36; P < 0.0001) and oral olanzapine (aHR 0.26; 95% CI 0.17-0.40; P < 0.0001).

CONCLUSIONS

Clozapine and olanzapine are the most effective and safest treatment options in those discontinuing clozapine for undefined reasons. Clozapine should therefore be reconsidered in patients with schizophrenia who previously discontinued this compound.

Comparative Effectiveness of Antipsychotics for Risk of Attempted or Completed Suicide Among Persons With Schizophrenia

OBJECTIVE

The objective of our study was to investigate the comparative effectiveness of antipsychotics for the risk of attempted or completed suicide among all patients with schizophrenia in Finland and Sweden.

METHODS

Two nationwide register-based cohort studies were conducted, including all individuals with schizophrenia in Finland (n = 61 889) and Sweden (n=29 823). The main exposure was 10 most commonly used antipsychotic monotherapies; also, adjunctive pharmacotherapies were investigated. The main outcome measure was attempted or completed suicide, which was analyzed with within-individual models by comparing use and nonuse periods in the same individual to minimize selection bias. Sensitivity analyses included attempted suicide (hospitalization only) as an outcome.

RESULTS

Compared with no use of antipsychotics, clozapine use was the only antipsychotic consistently associated with a decreased risk of suicidal outcomes. Hazard ratios (HRs) and 95% CIs for attempted or completed suicide were 0.64 (0.49-0.84) in the Finnish cohort and 0.66 (0.43-0.99) in the Swedish cohort. No other antipsychotic was associated with a reduced risk of attempted and/or completed suicide. Benzodiazepines and Z-drugs were associated with an increased risk of attempted or completed suicide (HRs: 1.29-1.30 for benzodiazepines and 1.33-1.62 for Z-drugs).

CONCLUSION

Clozapine was the only antipsychotic associated with decreased risk of attempted or completed suicide among patients with schizophrenia, and it should be considered as first-line treatment for high-risk patients.

Detection of medications associated with Alzheimer's disease using ensemble methods and cooperative game theory

OBJECTIVE

To study the feasibility of evaluating feature importance with Shapley Values and ensemble methods in the context of pharmacoepidemiology and medication safety.

METHODS

We detected medications associated with Alzheimer's disease (AD) by examining the additive feature attribution with combined approach of Gradient Boosting and Shapley Values in the Medication use and Alzheimer's disease (MEDALZ) study, a nested case-control study of 70,719 verified AD cases in Finland. Our methodological approach is to do binary classification using Gradient boosting (an ensemble of weak classifiers) in a supervised learning manner. Then we apply Shapley Values (from cooperative game theory) to analyze how feature combinations affect the classification result. Medication use with a five to one year time-window before AD diagnosis was ascertained from Prescription register.

RESULTS

Antipsychotics with low or medium dose, antidepressants with medium to high dose, and cardiovascular medications with medium to high dose were identified as the contributing features for separating cases with AD from controls. Medium to high amount of irregularity in the purchase pattern were an indicating feature for separating AD cases from controls. The similarity of medication purchases between AD cases and controls made the feature evaluation challenging.

CONCLUSIONS

The combined approach of Gradient Boosting and feature evaluation with Shapley Values identified features that were consistent with findings from previous hypothesis-driven studies. Additionally, the results from the additive feature attribution identified new candidates for future studies on AD risk factors. Our approach also shows promise for studies based on observational studies, where feature identification and interactions in populations are of interest; and the applicability of using Shapley Values for evaluating feature relevance in pattern recognition tasks.

Using the waiting time distribution with random index dates to estimate prescription durations in the presence of seasonal stockpiling

PURPOSE

A pervasive problem in registry-based pharmacoepidemiological studies is what exposure duration to assign to individual prescriptions. The parametric waiting time distribution (WTD) has been proposed as a method to estimate such durations. However, when prescription durations vary due to seasonal stockpiling, WTD estimates will vary with choice of index date. To counter this, we propose using random index dates.

METHODS

Within a calendar period of a given length, δ, we randomly sample individual index dates. We include the last prescription redemption prior to the index date in the analysis. Only redemptions within distance δ of the index date are included. In a simulation study with varying types and degrees of stockpiling at the end of the year, we investigated bias and precision of the reverse WTD with fixed and random index dates, respectively. In addition, we applied the new method to estimate durations of Norwegian warfarin prescriptions in 2014.

RESULTS

In simulation settings with stockpiling, the reverse WTD with random index dates had low relative biases (-0.65% to 6.64%) and high coverage probabilities (92.0% to 95.3%), although when stockpiling was pronounced, coverage probabilities decreased (2.7% to 85.8%). Using a fixed index date was inferior. The estimated duration of warfarin prescriptions in Norway using random index dates was 131 (130; 132) days.

CONCLUSIONS

In the presence of seasonal stockpiling, the WTD with random index dates provides estimates of prescription durations, which are more stable, less biased and with better coverage when compared to using a fixed index date.

Antiepileptic drug use and mortality among community-dwelling persons with Alzheimer disease

Objective

To evaluate the risk of death in relation to incident antiepileptic drug (AED) use compared with nonuse in people with Alzheimer disease (AD) through the assessment in terms of duration of use, specific drugs, and main causes of death.

Methods

The MEDALZ (Medication Use and Alzheimer Disease) cohort study includes all Finnish persons who received a clinically verified AD diagnosis (n = 70,718) in 2005–2011. Incident AED users were identified with 1-year washout period. For each incident AED user (n = 5,638), 1 nonuser was matched according to sex, age, and time since AD diagnosis. Analyses were conducted with Cox proportional regression models and inverse probability of treatment weighting (IPTW).

Results

Nearly 50% discontinued AEDs within 6 months. Compared with nonusers, AED users had an increased relative risk of death (IPTW hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.12–1.36). This was mainly due to deaths from dementia (IPTW HR, 1.62; 95% CI, 1.42–1.86). There was no difference in cardiovascular and cerebrovascular deaths (IPTW HR, 0.98; 95% CI, 0.67–1.44). The overall mortality was highest during the first 90 days of AED use (IPTW HR, 2.40; 95% CI, 1.91–3.03). Among users of older AEDs, relative risk of death was greater compared to users of newer AEDs (IPTW HR, 1.79; 95% CI, 1.52–2.16).

Conclusion

In older vulnerable patients with a cognitive disorder, careful consideration of AED initiation and close adverse events monitoring are needed.

Metformin and Risk of Alzheimer's Disease Among Community-Dwelling People With Diabetes: A National Case-Control Study

CONTEXT

Type 2 diabetes has been linked with an increased risk of Alzheimer's disease (AD). Studies on the association between metformin use and AD have reported conflicting results.

OBJECTIVE

To investigate whether metformin use modifies the association between diabetes and incident, clinically verified AD.

DESIGN

Nested case-control study.

SETTING

All community-dwelling people in Finland.

PARTICIPANTS

Cases were all community-dwelling Finns with AD diagnosed from 2005 to 2011 and with diabetes diagnosed ≥ 3 years before AD (n = 9862). Cases were matched with up to 2 control persons by age, sex, and diabetes duration (n = 19 550).

MAIN OUTCOME MEASURE

Cumulative metformin exposure was determined from reimbursed dispensings over a 10- to 16-year period. Adjusted odds ratios (aORs) were calculated using conditional logistic regression to estimate associations, with adjustment for potential confounders.

RESULTS

A total of 7225 (73.3%) cases and 14528 (74.3%) controls received metformin at least once. Metformin use (ever use) was not associated with incident AD (aOR 0.99; 95% confidence interval [CI], 0.94-1.05). The adjusted odds of AD were lower among people dispensed metformin for ≥ 10 years (aOR 0.85; 95% CI, 0.76-0.95), those dispensed cumulative defined daily doses (DDDs) of < 1825-3650 (aOR 0.91; 95% CI, 0.84-0.98) and > 3650 DDDs (aOR 0.77; 95% CI, 0.67-0.88), and among persons dispensed an average of 2 g metformin daily (aOR 0.89; 95% CI, 0.82-0.96).

CONCLUSION

In this large national sample we found no evidence that metformin use increases the risk of AD. Conversely, long-term and high-dose metformin use was associated with a lower risk of incident AD in older people with diabetes.

Opioid Use After Hospital Care due to Hip Fracture Among Community-Dwelling Persons With and Without Alzheimer's Disease

BACKGROUND

Hip fractures are common among persons with Alzheimer's disease (AD), but problems in pain assessment may lead to insufficient analgesia after hospitalization.

OBJECTIVE

We investigated the prevalence of opioid use in the 6 months after discharge from hospital care due to hip fracture among community-dwellers with and without AD.

SETTING AND METHOD

The Medication use and Alzheimer's disease (MEDALZ) cohort was used for this study, consisting of all community-dwelling persons newly diagnosed with AD during 2005-2011 in Finland and their comparison persons without AD matched on age, sex, and region of residence at the time of AD diagnosis. Data were collected from nationwide healthcare registers.

MAIN OUTCOME MEASURES

We investigated opioid use versus non-use in persons with and without AD in the 6 months after discharge from hospital care due to hip fracture.

RESULTS

Altogether 2342 persons with AD and 1615 persons without AD, discharged to community settings within ≤ 120 days after a hip fracture, were included. A higher percentage of persons with AD used opioids compared to those without AD, 39.5% [95% confidence interval (CI) 37.5-41.5] versus 31.2% (95% CI 28.9-33.5). Persons with AD used more frequently strong opioids during the first 3 months and buprenorphine during the 6-month period, and used weak opioids less frequently after the first month after discharge compared to those without AD.

CONCLUSIONS

Frequent opioid use after hospital care due to hip fracture may indicate increased attention to pain among persons with AD. Nevertheless, the benefits and harms of opioid use should be evaluated regularly in community-dwelling older persons.

Prevalence of cardiovascular drug use before and after diagnosis of Alzheimer's disease

BACKGROUND

Both cardiovascular diseases and Alzheimer's disease (AD) are common in aging populations. We investigated the prevalence of cardiovascular (CV) drug use in relation to AD diagnosis, and compared the prevalence to a matched cohort without AD.

METHODS

Point prevalence of CV drugs was counted every six months, from five years before to five years after AD diagnosis in the register-based Medication Use and Alzheimer's disease (MEDALZ) study, including community dwellers who received a clinically verified AD diagnosis during 2005-2011 in Finland, and compared to a matched cohort without AD. Data on drugs purchases was extracted from the Prescription Register by Anatomical Therapeutic Chemical-classification system codes C* (excluding C04 and C05) and modelled to use periods with PRE2DUP method.

RESULTS

Before AD diagnosis, the prevalence of CV drug use was higher in persons with AD (RR 1.04; confidence interval (CI) 1.02-1.06). At the index date (AD diagnosis date), the prevalence of CV drug use was similarly among persons with AD (75.8%), in comparison to matched cohort without AD (73.4%). However, after that, the prevalence of CV drug use started decline in persons with AD.

CONCLUSIONS

The decline in use of CV drugs after AD diagnosis likely reflects discontinued need for treatment due to weight loss, frailty, decline in blood pressure and serum lipid levels. It may also reflect the change in prescribing due to adverse events and priorities of care to improve the quality of end-of-life.

Use of antidepressants and mood stabilizers in persons with first-episode schizophrenia

Purpose

Antipsychotics are first-line treatment of schizophrenia. They are often accompanied by adjunctive treatments, such as antidepressant (AD) or mood stabilizer (MS), although there is only limited information of their use in first-episode schizophrenia. This study aimed to investigate AD and MS initiation and factors associated with initiation in persons with first-episode schizophrenia.

Methods

Register-based data was utilized to identify persons who received inpatient care due to schizophrenia during 1996–2014 in Finland and who did not use AD or MS at the time of first inpatient care diagnosis of schizophrenia (N = 7667, mean age 40.2, SD 18.2). Drug purchase data (1995–2017) was obtained from the National Prescription register and modelled with PRE2DUP method. Initiations of AD and MS use were followed up 3 years from first schizophrenia diagnoses. Cox proportional hazard models were used to investigate factors associated with AD or MS initiation.

Results

Among persons with first-episode schizophrenia, 35.4% initiated AD and 14.1% initiated MS use within three years from diagnoses. Female gender, younger age, and benzodiazepine use were associated with higher risk of AD and MS initiation. The number of previous psychoses was associated with decreased risk of AD and increased risk of MS initiation.

Conclusion

Clinical guidelines rarely recommend the use of AD or MS as adjunctive treatment in persons with schizophrenia. However, this population is often treated with AD or MS. More studies are needed to evaluate benefits and risks of these medications as adjunctive treatment of schizophrenia.

Antiepileptic Drug Use and the Risk of Stroke Among Community-Dwelling People With Alzheimer Disease: A Matched Cohort Study

Background People with Alzheimer disease ( AD ) are more predisposed to seizures than older people in general, and use of antiepileptic drugs ( AED s) is more frequent. AED use has been linked to a higher risk of vascular events in the general population; however, it is not evident whether the same risk exists in people with AD . We assessed the risk of stroke associated with incident AED use among people with AD . Methods and Results The MEDALZ (Medication Use and Alzheimer's Disease) cohort includes all Finnish people who received a clinically verified AD diagnosis (N=70718) from 2005 to 2011. People with previous strokes were excluded. For each incident AED user (n=5617) one nonuser was matched according to sex, age, and time since AD diagnosis. Analyses were conducted with Cox proportional hazards models and inverse probability of treatment weighting. Compared with nonuse, AED use was associated with an increased risk of stroke (inverse probability of treatment weighting hazard ratio ( HR ), 1.37; 95% confidence interval [CI], 1.07-1.74). The risk was strongest during the first 90 days (adjusted HR , 2.36; 95% CI , 1.25-4.47) of AED use. According to stroke type, the association was with ischemic strokes (inverse probability of treatment weighting HR , 1.34; 95% CI , 1.00-1.79) and hemorrhagic ones (inverse probability of treatment weighting HR , 1.44; 95% CI , 0.86-2.43). The stroke risk of users of older AED s did not differ from that of the users of newer AED s (adjusted HR , 1.04; 95% CI , 0.71-1.53). Conclusions AED use was related to an increased risk of stroke, regardless of AED type. Our results highlight caution in AED use in this vulnerable population.

Incidence and Prevalence of Antiepileptic Medication Use in Community-Dwelling Persons with and without Alzheimer's Disease

BACKGROUND

Although antiepileptic drugs (AEDs) have a potential for adverse drug reactions in older populations, little is known about their use in relation to Alzheimer's disease (AD) diagnosis.

OBJECTIVES

In this study, we investigated the incidence and prevalence of AED use in relation to AD diagnosis.

METHODS

The MEDALZ-study includes all Finnish persons who received clinically verified AD diagnoses (n = 70,718) during 2005-2011 and a matched comparison cohort without AD (n = 70,718). AD diagnoses were identified from the Special Reimbursement Register. We used the Prescription Register to identify dispensed AEDs. Incident AED users were identified with a one-year washout period 9-10 years before AD diagnosis, and incidence rates per 100 person-years were calculated for each six-month period from nine years before to five years after AD diagnosis. Prevalence was assessed as proportion using AEDs during each six-month time period for incident use.

RESULTS

Persons with AD were more likely to use AEDs during the study period (4.3%) than persons without AD (3.2%). The incidence and prevalence of AED use was higher among persons with AD and increased around the time of AD diagnosis. Epilepsy diagnoses did not explain these differences. Persons with AD were more likely to use older AEDs.

CONCLUSION

Our study highlights the need to balance effective symptom control with the possible risks of treatment.

Accumulation of Hospital Days Among Antipsychotic Initiators With Alzheimer's Disease

OBJECTIVES

To compare the accumulation of hospital days, a proposed proxy for overall drug safety, between antipsychotic initiators and noninitiators with Alzheimer's disease (AD).

DESIGN

Nationwide exposure-matched cohort.

SETTING AND PARTICIPANTS

Finnish community dwellers who received an incident AD diagnosis in 2005‒2011 (n = 70,718). For each antipsychotic initiator, 1 noninitiator was matched on age, sex, and time since AD diagnosis (n = 19,909 matched pairs).

MEASURES

Accumulation of hospital days was measured during a 2-year follow-up from the national hospital discharge register. Antipsychotic use was ascertained from the National Prescription Register. Association between antipsychotic initiation and accumulation of hospital days was analyzed using negative binomial model.

RESULTS

During the 2-year follow-up, antipsychotic initiators were hospitalized on average for 52.5 (standard deviation 97.7) days and matched noninitiators for 34.7 (standard deviation 72.4) days. Of antipsychotic initiators 23.8% and of noninitiators, 34.1% did not have any hospital days. Antipsychotic initiators had 53% more hospital days (adjusted incidence rate ratio 1.53; 95% confidence interval 1.47‒1.59) than noninitiators. Strongest associations were observed during the first 6 months. Antipsychotic initiators had more hospital days with primary diagnosis codes of dementia; mental and behavioral disorders; factors influencing health status; diseases of the respiratory, genitourinary, and circulatory system; certain infectious and parasitic diseases; and symptoms not elsewhere classified, than noninitiators.

CONCLUSIONS AND IMPLICATIONS

Antipsychotic initiators accumulated more hospital days than noninitiators, especially within the first 6 months after initiation. This may indicate adverse events or difficulties in treating the most severe behavioral and psychological symptoms of dementia and health problems triggering them. After initiating antipsychotics, careful and regular monitoring is needed to assess response and decrease the risk of adverse effects and events.

Hospitalization after Oral Antibiotic Initiation in Finnish Community Dwellers with and without Alzheimer's Disease: Retrospective Register-Based Cohort Study

BACKGROUND

Persons with Alzheimer's disease (AD) are frequently hospitalized from infection-related causes. There are no previous studies investigating hospitalization associated with antibiotic initiation in persons with AD.

OBJECTIVE

To investigate the frequency and risk of hospitalization associated with oral antibiotic initiation among community dwellers with and without AD.

METHODS

We performed a retrospective register-based study utilizing register-based Medication Use and Alzheimer's disease (MEDALZ) cohort. It includes all community dwellers diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Antibiotic use was initiated by 34,785 persons with and 36,428 without AD. Drug use data were collected from Prescription Register and comorbidities from Special Reimbursement and Hospital Care Registers. Infection diagnoses were collected from the Hospital Care Register. Factors associated with hospitalization were estimated utilizing logistic regression models.

RESULTS

Risk of hospitalization following antibiotic initiation was higher among antibiotic initiators with AD than without AD (adjusted odds ratio, aOR, 1.37, 95% Cl 1.28-1.46).Strongest association with hospitalization was found for oral glucocorticoid use, aOR 1.41 (1.25-1.59); epilepsy, aOR 1.33 (1.10-1.63); and active cancer, aOR 1.30 (1.14-1.49). Among initiators of cephalexin, pivmecillinam, amoxicillin/amoxicillin, and enzyme inhibitor and doxycycline, persons with AD were more frequently hospitalized than persons without AD. A quarter of hospitalized antibiotic initiators had infection diagnosis in their hospital care records.

CONCLUSIONS

Persons with AD initiating an antibiotic had a higher risk for hospitalization than antibiotic initiators without AD. Further research is needed to determine whether infection-related hospitalization could be reduced.

Long-term thiazide use and risk of low-energy fractures among persons with Alzheimer's disease-nested case-control study

We investigated the association between thiazide use and the risk of low-energy fractures among community dwellers with Alzheimer's disease. Longer use was associated with a decreased risk of low-energy fractures. This study extends the previous knowledge of reduced fracture risk of thiazides to persons with Alzheimer's disease.

INTRODUCTION

To investigate the association between thiazide use and the risk of low-energy fractures (LEF), and hip fracture among community dwellers with Alzheimer's disease (AD). No prior study has evaluated the effect of thiazides on LEF risk of AD patients.

METHODS

LEF cases were identified from the MEDALZ study, including all community-dwelling persons diagnosed with AD in Finland 2005-2011. During the follow-up from AD diagnoses until the end of 2015, cases with LEF (N = 10,416) and hip fracture (N = 5578) were identified. LEF cases were matched with up to three controls without LEF, according to time since AD diagnosis, age and gender. Thiazide use identified from the Prescription register data was modeled with PRE2DUP method. Current use was defined in 0-30 days' time window before the fracture/matching date, and duration of current use was assessed. The association between thiazide exposure and LEFs was assessed with conditional logistic regression.

RESULTS

Current thiazide use was observed in 10.5% of LEF cases and 12.5% of controls. Current thiazide use was associated with a decreased risk of LEF (adjusted OR [aOR] 0.83, 95% CI 0.77-0.88). In terms of the duration of use, no association was observed with short-term use (< 1 year or 1-3 years), while longer use (> 3 years) was associated with a reduced risk of LEF (aOR 0.77, 95% CI 0.71-0.83) and hip fracture (aOR 0.68, 95% CI 0.60-0.78).

CONCLUSIONS

Our study extends the previous knowledge of reduced fracture risk of thiazides to persons with AD, a population with significantly increased background risk of fractures.

Collection of antirheumatic medication data from both patients and rheumatologists shows strong agreement in a real-world clinical cohort: the Ontario Best Practices Research Initiative-a rheumatoid arthritis cohort

OBJECTIVES

The objective of the study was to examine the agreement between patient- and rheumatologist-reported antirheumatic medication (ARM) use in the Ontario Best Practices Research Initiative.

STUDY DESIGN AND SETTING

We included adult patients who enrolled on or after September 1st 2010 and compared ARM use where rheumatologist visits and interviews occurred within 60 days of each other. Kappa statistic was used to measure agreement. We calculated sensitivity, specificity, and positive and negative predictive value, considering patient-reported data as the gold standard. To examine factors associated with agreement, a hierarchical generalized linear model was used. A subset analysis was also completed to compare start and stop dates of ARM.

RESULTS

Overall agreement for ARM was good with higher sensitivity and lower specificity for conventional synthetic disease-modifying antirheumatic drugs compared with biologic disease-modifying antirheumatic drugs. Increased Health Assessment Questionnaire pain index and 28 disease activity score-erythrocyte sedimentation rate (DAS28-ESR) were significantly associated with lower agreement. Reporting stop dates was higher (19.4%) for patient-reported data compared with rheumatologist-reported data (13.1%).

CONCLUSION

ARM reports had strong agreement particularly for patients who have low disease activity and pain. ARM discontinuation was reported more frequently by patients, which may indicate that patients may be discontinuing use of their rheumatoid arthritis medications before consulting their rheumatologist.

A systematic review of methods for determining cross-sectional active medications using pharmacy databases

PURPOSE

Pharmacy dispensing databases are often used to identify patients' medications at a particular time point, for example to measure prescribing quality or the impact of medication use on clinical outcomes. We performed a systematic review of studies that examined methods to assess medications in use at a specific point in time.

METHODS

Comprehensive literature search to identify studies that compared active medications identified using pharmacy databases to medications identified using nonautomated data sources. Two investigators independently reviewed abstracts and full-text material.

RESULTS

Of 496 studies screened, 29 studies evaluating 50 comparisons met inclusion criteria. Twenty-nine comparisons evaluated fixed look-back period approaches, defining active medications as those filled in a specified period prior to the index date (range 84-730 days). Fourteen comparisons evaluated medication-on-hand approaches, defining active medications as those for which the most recent fill provided sufficient supply to last through the study index date. Sensitivity ranged from 48% to 93% for fixed look-back period approaches and 35% to 97% for medication-on-hand approaches. Interpretation of comparative performance of methods was limited by use of different reference sources, target medication classes, and databases across studies. In four studies with head-to-head comparisons of these methods, sensitivity of the medication-on-hand approach was a median of 7% lower than the corresponding fixed look-back approach.

CONCLUSIONS

The reported accuracy of methods for identifying active medications using pharmacy databases differs greatly across studies. More direct comparisons of common approaches are needed to establish the accuracy of methods within and across populations, medication classes, and databases.

Antiepileptic Drugs and Accumulation of Hospital Days Among Persons With Alzheimer's Disease

OBJECTIVES

To compare the accumulation of hospital days between initiators and noninitiators of antiepileptic drugs (AEDs) among persons with Alzheimer's disease (AD).

DESIGN

Exposure-matched cohort study.

SETTING AND PARTICIPANTS

Persons newly diagnosed with AD in 2005-2011 (n = 70,718) and initiating AED use identified from Finnish health care registers. For each AED initiator, 1 noninitiator matched on age, sex, and time since AD diagnosis was selected. Persons with epilepsy were excluded from the study.

METHODS

Association between AED initiation or use of individual AEDs and accumulation of hospital days during a 2-year follow-up was assessed using negative binomial model.

RESULTS

AED initiators (n = 4432) were hospitalized on average for 43.7 (SD: 88.3) days and matched noninitiators for 32.2 (SD: 71.3) days during the 2-year follow-up. Altogether, 27.3% of the AED initiators and 35.6% of the noninitiators had no hospital days during the study period. Number of accumulated hospital days during the follow-up was 31% higher [adjusted incidence rate ratio (aIRR): 1.31, 95% confidence interval (CI): 1.19-1.43] among AED initiators than the noninitiators. Hospital days due to diseases of the nervous system excluding dementia (aIRR: 2.72, 95% CI: 1.72-4.31), musculoskeletal system (aIRR: 2.49, 95% CI: 1.73-3.58), respiratory system (aIRR: 1.89, 95% CI: 1.47-2.43), and mental and behavioral disorders excluding dementia (aIRR: 1.96, 95% CI: 1.02-3.79) were more common among the AED initiators than noninitiators. Among pregabalin (aIRR: 0.65, 95% CI: 0.56-0.77), gabapentin (aIRR: 0.66, 95% CI: 0.49-0.88), and clonazepam (aIRR: 0.73, 95% CI: 0.55-0.96) initiators, the number of accumulated hospital days was 27% to 35% lower than the days accumulated among the initiators of valproic acid.

CONCLUSIONS AND IMPLICATIONS

AED initiators had more hospital days than noninitiators. Pregabalin and gabapentin were associated with a lower number of hospital days than valproic acid. Further research is needed on the reasons for these findings.

Systemic Estrogen Use and Discontinuation After Alzheimer's Disease Diagnosis in Finland 2005-2012: A Nationwide Exposure-Matched Cohort Study

BACKGROUND

It is unknown whether cognitive status or diagnosed cognitive decline affects estrogen use.

OBJECTIVES

We assessed how common systemic estrogen use was among community-dwellers with Alzheimer's disease (AD) and a matched comparison cohort without AD.

METHODS

This study included an exposure-matched cohort of all Finnish community-dwelling women who received a clinically verified diagnosis of AD in 2005-2011 (N = 46,116; index cases) and an equally sized matched comparison cohort without AD. Follow-up began on the matching date (date of the AD diagnosis of the index case). Data on systemic estrogen use were obtained from the prescription register. Use initiation and discontinuation were assessed.

RESULTS

Altogether 3.1% of women with AD and 4.3% of women without AD used estrogen during the follow-up period. Only < 0.5% initiated use during the follow-up period, but 3.7% continued use until death. The prevalence of estrogen use 1 year after the AD diagnosis declined in 2005-2011.

CONCLUSIONS

There were no major differences in systemic estrogen use among Finnish women with AD when compared to those without AD. Although some persons initiated estrogen use after AD diagnosis and/or at an advanced age, the observed use patterns were mainly consistent with the current recommendations.

Comparative Effectiveness of Antipsychotic Drugs for Rehospitalization in Schizophrenia-A Nationwide Study With 20-Year Follow-up

Very little is known about the comparative long-term effectiveness of novel antipsychotics in relapse prevention, especially in first-episode schizophrenia. Nationwide data from Finnish health care registers were gathered prospectively for all persons with periods of inpatient care due to schizophrenia in Finland during 1972-2014. Altogether 62250 persons were included in the prevalent cohort, and 8719 in the incident (first-episode schizophrenia) cohort. The follow-up for antipsychotic use started at 1996 for the prevalent cohort, and at the first discharge from inpatient care for the incident cases. Within-individual Cox regression models for risk of psychiatric and all-cause hospitalization were constructed to compare risk during antipsychotic use and no use using individual as his/her own control to eliminate selection bias. With follow-up time up to 20 years (median = 14.1, interquartile range = 6.9-20.0), 59% of the prevalent cohort were readmitted to psychiatric inpatient care. Olanzapine long-acting injection (LAI; adjusted hazard ratio = 0.46, 95% confidence interval = 0.36-0.61), clozapine (0.51, 0.49-0.53), and paliperidone LAI (0.51, 0.40-0.66) were associated with the lowest risk of psychiatric rehospitalization in the prevalent cohort. Among first-episode patients, the lowest risks were observed for flupentixol LAI (0.24, 0.12-0.49), olanzapine LAI (0.26, 0.16-0.44), and perphenazine LAI (0.39, 0.31-0.50). Clozapine and LAIs were associated with the lowest risk of all-cause hospitalization in both cohorts. Clozapine and LAIs are the most effective treatments in preventing psychiatric and all-cause hospitalization among chronic and first-episode patients with schizophrenia.

Validity of electronic hospital discharge prescription records as a source of medication data for pharmacoepidemiological research

BACKGROUND

The advent of hospital electronic medical records (EMRs) with electronic prescribing provides considerable opportunity for pharmacoepidemiological research. However, validity of EMR prescribing data for research purposes is not well established. Validity concerns the percentage of cases in which medications and characteristics (name, type, formulation, dose) are true when verified with an independent data source. This study evaluated the validity of EMR discharge prescription data within the Eastern Health hospital network in Melbourne, Australia.

METHODS

A random sample of patients were selected who had a diagnosis of atrial fibrillation (AF) and were prescribed at least five medications. Prescription records from 2012 to 2015 were compared with pharmacy dispensing and hospital medical records (reference standards). Medication name, dose, directions and route of administration were compared. Discrepancies between data sources were categorized as omissions, additions, discrepancies in dose, medication form or route of administration or discrepancies in reordering. Sensitivities and 95% confidence intervals (CIs) for intended medication exposure were estimated for therapeutic classes.

RESULTS

A total of 5724 prescription orders for 479 patients for whom reference standards were available were included. There were 163 discrepancies (2.8%) between prescription records and reference standards. Additions were the most common data discrepancy (n = 65; ~1.1% of total prescriptions evaluated), followed by discrepancies in reordering (n = 34; 0.59%). Sensitivities for intended patient exposure to a medication for each therapeutic class at the first level of the Anatomical Therapeutic Chemical (ATC) classification system were between 97% and 100%. The genitourinary system and sex hormone level of the ATC system demonstrated the lowest sensitivity, (97.3%; 95% CI 92.0%-100%) and the cardiovascular system level demonstrated the highest sensitivity (99.9%; 95% CI 99.7%-100%).

CONCLUSION

EMR discharge prescription records for patients with AF are a valid information source for conducting pharmacoepidemiological research within Eastern Health in Melbourne, Australia. Further studies in different regions, countries and patient cohorts are required to establish validity of hospital EMR prescription records for pharmacoepidemiological research.

The risk of Alzheimer's disease associated with benzodiazepines and related drugs: a nested case-control study

OBJECTIVE

To assess the association between benzodiazepine and related drug (BZDR) use and risk of Alzheimer's disease (AD) with cumulative consumption and duration of use based models.

METHOD

A nationwide nested case-control study of all Finnish community-dwelling persons who received clinically verified AD diagnosis in 2005-2011 (N = 70 719) and their matched controls (N = 282 862). AD diagnosis was based on DSM-IV and NINCDS-ADRDA criteria. BZDR purchases were extracted from the Prescription Register since 1995. The association between BZDR use and AD was assessed using conditional logistic regression with 5-year lag time between exposure and outcome.

RESULTS

Benzodiazepine and related drug use was associated with modestly increased risk of AD (adjusted OR 1.06, 95% CI 1.04-1.08). A dose-response relationship was observed with both cumulative consumption and duration. Adjustment for other psychotropics removed the cumulative dose-response relationship by attenuating the ORs in the highest dose category.

CONCLUSION

Benzodiazepine and related drug use in general was associated with modestly increased risk of AD. No major differences were observed between different subcategories of BZDRs (i.e. benzodiazepines, Z drugs, short-/medium-acting or long-acting BZDRs). As dose-response relationship abolished after adjustment for other psychotropics, it is possible that the association may partially be due to antidepressants and/or antipsychotics, or concomitant use of these medications.

Antipsychotics and mortality in a nationwide cohort of 29,823 patients with schizophrenia

INTRODUCTION

It has remained controversial if antipsychotic treatment is associated with increased or decreased mortality among patients with schizophrenia, and if there are any clinically meaningful differences between specific agents and routes of administration.

METHODS

We linked prospectively gathered nationwide register-based data during 2006-2013 to study all-cause mortality among all patients aged 16-64years with schizophrenia in Sweden (N=29,823 in total; N=4603 in the incident cohort). Multivariate Cox regression models were adjusted for clinical and sociodemographic covariates. Sensitivity analyses with the incident cohort were conducted to control for survival bias.

RESULTS

During the mean follow-up of 5.7years, 2515 patients (8.4%) died. During the maximum follow-up (7.5years), the lowest cumulative mortality was observed for second generation (SG) long-acting injection (LAI) use (7.5%). Adjusted hazard ratios (aHRs) compared to SG LAI use were 1.37 (95%CI 1.01-1.86) for first generation (FG) LAIs, 1.52 (1.13-2.05) for SG orals, 1.83 (1.33-2.50) for FG orals, and 3.39 (2.53-4.56) for nonuse of antipsychotics. Concerning specific agents, the lowest mortality was observed for once-monthly paliperidone LAI (0.11, 0.03-0.43), oral aripiprazole (0.22, 0.15-0.34), and risperidone LAI (0.31, 0.23-0.43). In pairwise comparison, LAIs were associated with 33% lower mortality than equivalent orals (0.67, 0.56-0.80). The results with incident cohort were consistent with the primary analyses.

CONCLUSIONS

Among patients with schizophrenia, LAI use is associated with an approximately 30% lower risk of death compared with oral agents. SG LAIs and oral aripiprazole are associated with the lowest mortality.

Impact of opioid initiation on antipsychotic and benzodiazepine and related drug use among persons with Alzheimer's disease

ABSTRACTBackground:We analyzed the impact of opioid initiation on the prevalence of antipsychotic and benzodiazepine and related drug (BZDR) use among community-dwelling persons with Alzheimer's disease (AD).

METHODS

We utilized the register-based Medication use and Alzheimer's disease (MEDALZ) cohort for this study. We included all community-dwelling persons diagnosed with AD during 2010-2011 in Finland initiating opioid use (n = 3,327) and a matched cohort of persons not initiating opioids (n = 3,325). Interrupted time series analyses were conducted to compare the prevalence of antipsychotic and BZDR use in 30-day periods within six months before opioid initiation to 30-day periods six months later.

RESULTS

Before opioid initiation, prevalence of antipsychotic use among opioid initiators was 13.3%, 18.3% at opioid initiation, and 17.3% six months later. Prevalences of BZDR use were 27.1% six months prior, 28.9% at opioid initiation, and 26.9% six months later. After opioid initiation, antipsychotic and BZDR use declined by 0.3 percentage points (pps, 95% confidence interval 0.1-0.5) and 0.4 pps (0.2-0.7) per month, respectively, until the end of the follow-up. Compared to persons not initiating opioid use, opioid initiation immediately resulted in an increase in prevalence of 1.9 pps (0.9-2.8) for antipsychotics and of 1.6 pps (0.9-2.2) for BZDR use. However, in total there was a comparative decrease of 0.5 pps (0.3-0.8) per month for antipsychotics and of 0.4 pps (0.2-0.6) for BZDR use until the end of the follow-up.

CONCLUSION

Our results suggest that opioid initiation may reduce antipsychotic and BZDR use among persons with AD.

Empirical validation of the reverse parametric waiting time distribution and standard methods to estimate prescription durations for warfarin

PURPOSE

In many prescription databases, the duration of treatment for the single prescription is not recorded. This study aimed to validate 2 different types of approaches for estimating prescription durations, using the oral anticoagulant warfarin as a case.

METHODS

The approaches undergoing empirical validation covered assumptions of a fixed daily intake of either 0.5 or 1.0 defined daily dose (DDD), as well as estimates based on the reverse parametric waiting time distribution (rWTD), with different sets of covariates. We converted estimates of prescription duration to daily dose and compared them to prescribed daily dose as recorded in a clinical registry (using Bland-Altman plots). Methods were compared based on their average prediction error (logarithmic scale) and their limit of agreement ratio (ratio of mean error ± 1.96 SD after transformation to original scale).

RESULTS

Estimates of daily doses were underestimated by 19% or overestimated by 62% when assumptions of 0.5 or 1.0 DDD were applied. The limit of agreement ratio was 6.721 for both assumptions. The rWTD-based approaches performed better when using the estimated mean value of the inter-arrival density, yielding on average negligible bias (relative difference of 0 to 2%) and with limit of agreement ratios decreasing upon additional covariate adjustment (from 6.857 with no adjustment to 4.036 with the fully adjusted model).

CONCLUSIONS

Comparing the different methods, the rWTD algorithm performed best and led to unbiased estimates of prescribed doses and thus prescription durations and reduced misclassification on the individual level upon inclusion of covariates.

Real-world Effectiveness of Pharmacologic Treatments for the Prevention of Rehospitalization in a Finnish Nationwide Cohort of Patients With Bipolar Disorder

IMPORTANCE

Mood stabilizers and antipsychotics are the main maintenance treatments for bipolar disorder. Lithium is considered to be the most effective mood stabilizer, but very little is known about overall health outcomes associated with specific treatments and the comparative long-term effectiveness of specific psychotropics or routes of administration in the prevention of rehospitalizations.

OBJECTIVE

To study the comparative effectiveness of pharmacologic treatments in the prevention of rehospitalization in a nationwide cohort of patients with bipolar disorder.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined the risk of psychiatric, cardiovascular, and all-cause hospitalization from January 1, 1987, to December 31, 2012, among all patients in Finland who had been hospitalized for bipolar disorder (N = 18 018; mean follow-up time, 7.2 years) using prospectively gathered nationwide databases for hospitalization and dispensed medications. The primary analysis was within-individual analysis, in which each individual was used as his or her own control to eliminate selection bias. The study adjusted for the effect of concomitant psychotropic medications, duration of illness, and the temporal orders of exposure and nonexposure periods. Statistical analysis was conducted from January 1, 1996, to December 31, 2012.

MAIN OUTCOMES AND MEASURES

Adjusted hazard ratios (HRs) for rehospitalization were calculated.

RESULTS

Among the cohort (9558 women and 8460 men; mean [SD] age, 46.6 [17.0] years), 9721 patients (54.0%) had at least 1 psychiatric rehospitalization. In comparison between use and no use among specific agents reaching nominal statistical significance, risperidone long-acting injection (HR, 0.58 [95% CI, 0.34-1.00]), gabapentin (HR, 0.58 [95% CI, 0.44-0.77]), perphenazine long-acting injection (HR, 0.60 [95% CI, 0.41-0.88]), and lithium carbonate (HR, 0.67 [95% CI, 0.60-0.73]) were associated with the lowest risk of psychiatric rehospitalization. Concerning all-cause hospitalization, lithium (HR, 0.71 [95% CI, 0.66-0.76]) was associated with the lowest risk. The most frequently used antipsychotic treatment, quetiapine fumarate, showed only modest effectiveness (risk of psychiatric rehospitalization: HR, 0.92 [95% CI, 0.85-0.98]; risk of all-cause hospitalization: HR, 0.93 [95% CI, 0.88-0.98]). Long-acting injections were associated with substantially better outcomes compared with identical oral antipsychotics (risk of psychiatric rehospitalization: HR, 0.70 [95% CI, 0.55-0.90]; risk of all-cause hospitalization: HR, 0.70 [95% CI, 0.57-0.86]). Results from sensitivity analyses showed consistent beneficial effects only for lithium and for long-acting injections compared with their oral counterparts.

CONCLUSIONS AND RELEVANCE

Lithium was the most effective mood stabilizer, and long-acting injections the most effective antipsychotics, in preventing hospitalization due to mental or physical illness.

Proton pump inhibitor use and risk of hip fractures among community-dwelling persons with Alzheimer's disease-a nested case-control study

BACKGROUND

Hip fractures are a major health concern among older persons with Alzheimer's disease, who usually use many concomitant drugs for several diseases. Evidence of the association between proton pump inhibitor use and risk of hip fracture is contradictory.

AIM

To investigate whether the long-term use of proton pump inhibitor is associated with risk of hip fractures among community-dwelling persons with Alzheimer's disease.

METHODS

In this nested case-control study, the nationwide MEDALZ data were utilised. Community-dwelling persons with Alzheimer's disease who encountered incident hip fracture (N = 4818; mean age 84.1) were included as cases. Four controls were matched for each case at the date of hip fracture (N = 19 235; mean age 84.0). The association between hip fracture and duration of current PPI use (ongoing use during 0-30 days before the index date), and cumulative duration of use during 10 years before was investigated with conditional logistic regression.

RESULTS

Long-term or cumulative proton pump inhibitor use was not associated with an increased risk of hip fracture. Current proton pump inhibitor use was associated with an increased risk of hip fracture (adjusted OR 1.12, 95% CI 1.03-1.22). The risk was increased in short-term current use (<1 year) (adjusted OR 1.23, 95% CI 1.10-1.37).

CONCLUSIONS

The increased risk of hip fracture was evident only in short-term proton pump inhibitor use, but no association was found for long-term or cumulative use. Thus, our findings do not support previous assumptions that long-term proton pump inhibitor use would be associated with an increased risk of hip fractures.

Risk of death associated with new benzodiazepine use among persons with Alzheimer disease: A matched cohort study

OBJECTIVE

To investigate the risk of death associated with new benzodiazepine and related drug (BZDR) use in a nationwide cohort of persons with Alzheimer disease (AD).

METHODS

The register-based MEDALZ cohort, including all community-dwelling Finns diagnosed with AD during 2005 to 2011 (n = 70 718), was used. Clinically verified AD diagnoses were obtained from the Special Reimbursement Register. Drug use periods were modeled from BZDR purchases, derived from the Prescription Register. To study new users, persons who had any BZDR use during the year preceding the AD diagnosis were excluded. For each person initiating BZDR use (n = 10 380), 2 nonusers (n = 20 760) were matched on age, gender, and time since AD diagnosis. The outcome was 180-day mortality, and BZDR use was compared with nonuse with Cox regression. Multivariable analyses were adjusted for Charlson comorbidity index, socioeconomic position, hip fractures, psychiatric disorders, substance abuse, stroke, and other psychotropic drug use.

RESULTS

During the follow-up, 5 excess deaths per 100 person-years occurred during BZDR use in comparison to nonuse, and mortality rates were 13.4 (95% confidence interval [CI], 12.2-14.5) and 8.5 (95% CI, 7.9-9.1), respectively. Benzodiazepine and related drug use was associated with an increased risk of death (adjusted hazard ratio = 1.4 [95% CI, 1.2-1.6]), and the association was significant from the initiation of use. Benzodiazepine use was associated with an increased risk of death, whereas benzodiazepine-related drug use was not.

CONCLUSIONS

Benzodiazepine and related drug use was associated with an increased risk of death in persons with AD. Our results support treatment guidelines stating that nonpharmacological approaches should be the first-line option for symptomatic treatment of AD.